Form 3520-12 Fuel Manufacturer Notification for Motor Vehicle Fuel

EPA Form 3520-12 (11-01-2013)- Fuel Manufacturer Notification for Motor Vehicle Fuel

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Form Approval
OMB No. 2060-0150 Approval
Expires 10/31/2016

U.S. Environmental Protection Agency
Office of Transportation and Air Quality

Fuel Manufacturer Notification
for Motor Vehicle Fuel

* Required field

Leave Blank

* 1.Brand name(s) of the motor vehicle fuel covered by this notification (list): (Please separate each brand name by comma)

* 2. Company Name:

*

New Company

3. Company ID:

Registered Company

* 4. Street Address:
* Province:

* State:

* Country:

* City:

* Zip:

* 5. Type of Fuel
(a) Unleaded Premium Gasoline

(d) Grade 1-Diesel

(b) Unleaded Regular Gasoline

(e) Grade 2-Diesel

(c) Unleaded Midgrade Gasoline

(f) BioDiesel

6. Fuel properties, to the extent known:

(b) Olefins
(c) Saturates
(d) Polynuclear Organic Material
(e) Sulfur
(f) Trace Elements

Gasoline:
(g) Reid Vapor Pressure
(h) Distillation: 10% Point (°C)
(i) Distillation: End Point (°C)
(j) Research Octane Number
(k) Motor Octane Number
Diesel Fuel:
(I) Distillation: 90% Point (°C)
(m) Distillation: End Point (°C)
(n) Cetane Number or Index

(h) Other (Specify):
Percent by weight

Highest
(a) Aromatics

(g) Renewable Diesel

Lowest

Average

Methods of Analysis
(a) through (f) only

EPA Form 3520-12 (11-01-2013)- Fuel Manufacturer Notification for Motor Vehicle Fuel

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7. Additives to be used in the motor vehicle fuel:
Range of Additive Concentration

Leave Blank

(a) Commercial Name of
Additive

(b) Additive Manufacturer

(c) PurposeIn-Use
(d) High
of Additive

(e) Low (f) Average

(g) Units

EPA Form 3520-12 (11-01-2013)- Fuel Manufacturer Notification for Motor Vehicle Fuel

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* 8. Do you know of any analytical technique that can be used to detect the presence of any of the reported additives in this fuel and/
or measure their concentration therein?
No

Yes

If "Yes," attach separate sheet(s) providing the information.

* 9. Do you have any information developed by or for you concerning the mechanisms of action of any of the additives reported;
reactions between the additives and the motor vehicle fuel; the identification and/or measurement of the emission products of the
additives when used in the motor vehicle fuel; the effects of the additives on all emissions; the toxicity and any other public health or
welfare effects of the emission products of the additives; and/or the effects of the emission products of the gasoline additives on the
performance of emission control devices or systems?
If "Yes," attach separate sheet(s) providing summaries and a description of the test procedures
used in obtaining the information.

Yes

No

* 10. To the nearest percent, estimated for the third year of production, enter the percent of sales by Petroleum Administration for
Defense District (PADD) for the motor vehicle fuel. See instructions for the states in each PADD.

PADD1

PADD2

%

%

PADD3

%

PADD4

%

PADD5

%

* 11. Is this fuel derived only from conventional petroleum, heavy oil deposits, coal, tar sands, and/or oil sands?
No

Yes

12. Small Business Provisions - 40 CFR 79.58(d). (See instructions)
A manufacturer of a baseline or non baseline fuel whose average of the previous three years annual sales revenue is less than $50
million is exempt from the Tier 1 and Tier 2 health-effects testing requirements. A manufacturer of an atypical fuel whose average
of the previous three years annual sales revenue is less than $10 million is exempt from the Tier 2 requirements. If you believe that
you qualify for an exemption, enter below your sales revenue for each of the previous three years and the average.
(Note: In cases where subsidiary, divisional, or other complex business arrangements exist, the business entity to which this sales
level pertains is the parent company with ultimate ownership. The "ultimate" parent is defined as the uppermost headquarters or
topmost company encompassing all related parents, subsidiaries, divisions, branches, or other operating units. This definition
follows that used by the Small Business Administration. It also helps to ensure that a company will not subdivide merely to
become eligible for an exemption.)
Annual sales revenue 3 years ago: $
Annual sales revenue 2 years ago: $
Annual sales revenue 1 year ago: $
Average of above: $
Is the above average for the company named in Item 2?
Yes

No

If "No," complete the following:

Name of the parent company with ultimate ownership:

Street Address:
City:

State:

Province:

Zip:

Contact Name:

Phone:

Title:

Email:

Country:

EPA Form 3520-12 (11-01-2013)- Fuel Manufacturer Notification for Motor Vehicle Fuel

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13.Grouping Information - If you do not qualify for a small business provision, you must be a member of a testing group appropriate for
your fuel or supply the appropriate health-effects test information. This fuel is covered by the following testing group:
Group description:
Organizing entity:
Prefix:

Contact person:
Telephone:

(

First Name:

)

Last Name:
Fax:

Extension:

(

)

Email:
Street:
Address:

City:

State:

Zip:

Country:

Province:
OR

I have attached the appropriate information.
Yes

No

If "No," attach an explanation.

* 14. Confidential Business Information - You may assert a business confidentiality claim for certain items. If no claim is made, the
information may be made available to the public without further notice. All questions of confidentiality will be handled pursuant to
40 CFR 2.
Do you wish to assert a claim of confidentiality for any of items 6 through 13?
*

If "Yes," indicate "Yes" or "No" for each item below:

Yes

No
Item 6:

Yes

No

Item 7:

Yes

No

Item 8:

Yes

No

Item 9:

Yes

No

Item 10:

Yes

No

Item 11:

Yes

No

Item 12:

Yes

No

15. Attached Information - Are attachments included with this notification?
No

Yes

If "Yes," list below:

No

Yes

Are the attachments confidential?
If "Yes," also indicate on attachments.

Item 13:

Yes

No

EPA Form 3520-12 (11-01-2013)- Fuel Manufacturer Notification for Motor Vehicle Fuel

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16. Certification
To the best of my knowledge, the above is complete and correct.
I am authorized by the manufacturer to submit this information.
As per 40 CRF 79.11(g), the U.S Environmental Protection Agency would be notified in writing if certain
information in this notification were to change.
This fuel manufacturer will not represent, directly or indirectly, in any notice, circular, letter, or other written
communication, or any written, oral, or pictorial notice, or other announcement in any publication or by radio or
television, that registration of this fuel constitutes endorsement, certification, or approval by any agency of the
United States.
Signature:
* Date:
* Name of Signer
* Telephone:

(

Prefix:

)

First Name:

Last Name:
Fax:

Extension:

Title:

(

)

E-mail:

Check if the Contact Person is the same as the signer above.
* Contact Person: Prefix:
* Telephone:

(

)

Title:

Last Name:

First Name:
Fax:

Extension:

(

)

E-mail:

Comments:

Mail the completed form to:
U.S. Environmental Protection Agency
William Jefferson Clinton Building
Mail Code - 6405A
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Telephone (202) 343-9648
Fax (202) 343-2825
Email: [email protected]
Email: [email protected]
This office is operated by a contractor for the EPA.

or, via courier:
U.S. Environmental Protection Agency
William Jefferson Clinton Building
Room 6520V; (202) 343-9038
1200 Pennsylvania Ave, NW
Washington, DC 20004