Fuel Manufacturer Annual Report for Motor Vehicle Gasoline or Diesel Fuel

EPA Form 3520-12A - Fuel Manufacturer Annual Report Instructions ()

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Instructions

Fuel Manufacturer Annual Report

for Motor Vehicle Gasoline or Diesel Fuel

GENERAL INFORMATION
Any manufacturer of a fuel registered by the Environmental Protection Agency must submit a Fuel Manufacturer Annual Report
for that fuel in order to keep the registration in force.
Fuel Manufacturer Annual Reports are to be submitted on or before March 31 for the preceeding year or part thereof.
One copy of an Annual Report should be completed and submitted for each registered fuel.
Completed form(s) should be sent:
Via U.S. Postal Service
U.S. Environmental Protection Agency
William Jefferson Clinton Building
Mail Code - 6405A
1200 Pennsylvania Ave, NW
Washington, DC 20460

or

Via Courier
U.S. Environmental Protection Agency
William Jefferson Clinton Building
Room 9(202) 343-9038
1200 Pennsylvania Ave, NW
Washington, DC 20004

Telephone: (202) 343-9648
Fax: (202) 343-2825
email: [email protected]
[email protected]
Specific instructions for completing the form follow.
The EPA is responsible for assessing the impact on public health and welfare from exposure to motor vehicle emissions.
Knowledge of fuel composition, as reported by each manufacturer, is an important aspect of this program.
SPECIFIC INSTRUCTIONS
Please type (best results are obtained using standard fonts such as Courier or Arial) or print the information using a dark-colored
ink. If using a photocopied version of the form, please ensure the copy is clean and has been copied to 100% of the original page
size.
Item 1.

Company Name: Enter the company's legal name.

Item 1a. Company ID : If known, enter the EPA assigned Company ID.
Item 2.

Address : Enter the address of the company office responsible for submiting this form.

Item 3.

Report Year: Enter the year for which the company is submitting the report.

Item 4.

Fuel ID: Enter the EPA assigned Fuel ID. If you do not know it, leave blank.

Item 5.

Brand Name: List the brand name under which your company markets the fuel described on this form. If you market it
under more than one name, list the first name listed on the "Fuel Manufacturer Notification for Motor Vehicle Fuel," EPA
Form 3520-12.

Item 6.

Fuel Properties: To the extent known, provide the highest, lowest, and average concentrations, in weight percent, for the
listed characteristics/properties. Also, mark whether methods of analysis for (a) through (f) are the same as previously
reported.
If not, provide the correct method of analysis for the affected item. For any item for which measurements are not
available, enter "Not Measured." If a standard method of analysis is used, identify it (e.g., ASTM D1319), otherwise
describe the method used on a seperate sheet. Please use metric measurements.
Also provide characteristics (g) through (m) for the gasoline or diesel fuel you are reporting.

Item 7.

Mechanisms of Action: Self-explanatory.

Item 8.

Confidential Business Information: Check the number(s) of those items for which your company asserts a claim of

EPA Form 3520-12A - Fuel Manufacturer Annual Report Instructions (2013)

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confidentiality.
Item 9.

Certification: The notification form must be signed and dated by the fuel manufacturer or its authorized agent. The
printed name of the signer and the signer's telephone number should be given. If the form is signed by an authorized
agent, the company must provide a letter authorizing such agent.

OMB Control No. 2060-0150
Approval expires 10-31-2016
The public reporting and recordkeeping burden for this collection of information is estimated to
average 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. 20406. Include the OMB control number in any correspondence. Do not send the
completed form to this address.
NOTE: This office is operated by a contractor, SRA International for the EPA. Information submitted with this
form will be provided to SRA International for processing into a database at the registration office.