Form 3520-12Q Fuel Manufacturer Quarterly Report for Motor Vehicle Gas

EPA Form 3520-12Q (11-01-2013)- Fuel Manufacturer Quarterly Report 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

Leave Blank

Fuel Manufacturer Quarterly Report for
Motor Vehicle Gasoline or Diesel Fuel

* Required field

* 1a. Company ID:

* 1. Company Name:

* 3. Fuel ID:

* 2. Street Address:
* Country:

* City:

* Zip:

* State:

* 4. Report Year:

Province:
5. Quarterly Production Volume:

* 6. Quarter :

gal

(a) January through March

(c) July through September

(b) April through June

(d) October through December

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

8. Use during this quarter of US EPA registered additives previously reported for use in this fuel:

Leave Blank

(a) Commercial Name of Additive

(d) High

Range of Additive Concentration

(e) Low

(f) Average (g) Units

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

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* 9. 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 5 and/or 8?
*

No

Yes

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

Item 5:

Yes

No

Item 8:

Yes

No

10. 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:

First Name:

Last Name:

Title:

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

(

First Name:

)

Last Name:

Title:
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