5900-142 Pre-2005 Methyl Bromide Stocks Report

OMB Control Number: 2060-0482

Expiration Date: 6/30/15

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance methyl bromide pre-2005 stocks annual report (40 CFR 82.13)

note: form must be completed by any company that owns stocks of methyl bromide that were produced or imported prior to january 1, 2005.

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission

     

1.2 Year to Which This Report Applies

     

1.3 Original Submittal Re-submittal

1.4 Company Information

Company Name      

Street Address      

City      

State      

Zip Code      

1.5 Company Contact Identification

Reporting Company Contact Person      

E-mail Address      

Phone Number      

Fax Number      

1.6 Company Type (check all that apply)

Distributor

Third Party Applicator

Producer

Importer

1.7 Signature of Reporting Company Representative

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

Name      

Title      

Signature      

Date      

SEND COMPLETED FORMS TO:

For U.S. Postal Service: U.S. EPA Stratospheric Protection Division Office of Atmospheric Programs Mail Code: 6205T 1200 Pennsylvania Avenue, NW Washington, D.C. 20460

For Private Courier: U.S. EPA Stratospheric Protection Division Office of Atmospheric Programs Room 4355CC 1201 Constitution Avenue, NW Washington, D.C. 20004

A company may assert a claim of confidentiality for information submitted in this form by clearly marking that information as confidential. Such information shall be treated in accordance with EPA’s procedures for information claimed as confidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confidentiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2.203).

The public reporting and recordkeeping burden for this collection of information is estimated to average 1.3 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

U.S. Environmental Protection Agency stratospheric ozone protection program				class i controlled substance methyl bromide pre-2005 stocks annual report (40 CFR 82.13)
SECTION 2 TRANSACTION DATA
2.1 Company Name		     
2.2 Total Stocks of Pre-Phaseout Methyl Bromide*
      kg	Owned by reporting company as of December 31 of this year (including all quantities owned by reporting company that are held by other suppliers on the reporting company’s behalf)
* These quantities of stocks refer only to amount of methyl bromide that were produced or imported before January 1, 2005. Any quantities of newly produced critical use methyl bromide left in the reporting company’s possession as of December 31 of this year should be reported on form “Sales of Critical Use Methyl Bromide,” section 2.3.
2.3 Name(s) of Company(ies) which are Holding Stocks of Pre-Phaseout Methyl Bromide on Behalf of the Owner
Company Name:      			Amount Held (kg):      
Company Name:      			Amount Held (kg):      
Company Name:      			Amount Held (kg):      

EPA Form # 5900-142, Revised 7/14