Form 3520-12A Fuel Manufacturer Annual Report for Motor Vehicle Gasoli

EPA Form 3520-12A (11-01-2013)- Fuel Manufacturer Annual Report for Motor Vehicle Fuel

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

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

* Required field

Fuel Manufacturer Annual Report
for Motor Vehicle Gasoline or Diesel Fuel

* 1a. Company ID:

* 1. Company Name:

* 3. Fuel ID:

* 2. Street Address:
* Country:

* City:

Leave Blank

* State:

* Zip:

* 4. Report Year:

Province:
* 5. Brand name of the motor vehicle fuel covered by this report:

6. Fuel properties, to the extent known:

Percent by weight
Highest

(a) Aromatics (Diesel Only)
(b) Olefins (Diesel Only)
(c) Saturates (Diesel Only)
(d) Polynuclear Organic Material
(e) Sulfur (Diesel Only)
(f) Trace Elements

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

Lowest

Average

Methods of Analysis
Same as previously reported:
Yes
No if "No", identify below

EPA Form 3520-12A (11-01-2013)- Fuel Manufacturer Annual Report for Motor Vehicle Fuel

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7. For any additive that you reported you may use, do you have any information, not previously reported, concerning the mechanisms
of action of the additive; reactions between the additive and gasoline or diesel fuel; the identification and measurement of the emission
products of the additive when used in gasoline or diesel fuel; the effects of the additive on all emissions; the toxicity and any other public
health or welfare effects of the emission products of the additive; and/or, for gasoline only, the effects of the emission products of the
additive on the performance of emission control devices/systems?
No

Yes

If "Yes," attach separate sheet(s) providing summaries of such information and a description of the
test procedures used in obtaining the information.

* 8. 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 and /or 7?
*

Yes

No

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

Item 6:

Yes

No

Item 7:

Yes

No

9. Certification

To the best of my knowledge, the above is complete and correct.
I am authorized by the manufacturer to submit this information.

Signature:
* Date:
* Name of Signer:

Last Name:

First Name:

Title:

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

(

)

Title:

Last Name:

First Name:
Extension:

Fax:

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