5900-154 Certification of Order/Purchase of QPS Methyl Bromide

OMB Control Number: 2060-0170

Expiration Date: 6/30/15

U.S. Environmental Protection Agency stratospheric ozone protection program					class i controlled substance certification of order/purchase of qps methyl bromide (Sec 82.13)
SECTION 1	PURCHASER IDENTIFICATION AND METHYL BROMIDE USE
1.1 Date of Submission		     	1.2 Quantity of Methyl Bromide Ordered/ Purchased (kg)					     
1.3 Company Information
Purchaser Name      
Street Address      
City      				State      		Zip Code      
1.4 Company Contact Identification
Reporting Company Contact Person      				Phone Number      			Fax Number      
E-mail Address      
Quarantine Applications, with respect to Class I, Group VI controlled substances (methyl bromide), are treatments to prevent the introduction, establishment and/or spread of quarantine pests (including diseases), or to ensure their official control, where: (1) Official control is that performed by, or authorized by, a national (including state, tribal or local) plant, animal or environmental protection or health authority; (2) quarantine pests are pests of potential importance to the areas endangered thereby and not yet present there, or present but not widely distributed and being officially controlled. This definition excludes treatments of commodities not entering or leaving the United States or any State (or political subdivision thereof). Preshipment Applications, with respect to Class I, Group VI controlled substances (methyl bromide), are those non-quarantine applications applied within 21 days prior to export to meet the official requirements of the importing country or existing official requirements of the exporting country. Official requirements are those which are performed by, or authorized by, a national plant, animal, environmental, health or stored product authority.
1.5 Signature of Reporting Company Representative
I certify that the quantities of methyl bromide specified in Section 1.2 of this form are ordered/purchased and will be used exclusively for quarantine & preshipment applications as defined above, and not sold/ transferred to another person. 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:

The Company from Whom the Methyl Bromide is Being Ordered/Purchased

The public reporting and recordkeeping burden for this collection of information is estimated to average 2.1 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.

EPA Form # 5900-154, Revised 06/12