Fuel Manufacturer Quartly Report for Motor Vehicle Gasoline or Diesel Fuel

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

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Instructions

Fuel Manufacturer Quarterly 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 Quarterly
Report for that fuel in order to keep the registration in force.
Fuel Manufacturer Quarterly Reports are to be submitted within 45 days after the close of each calendar quarter.
One copy of a Quarterly 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 6520V; (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 production 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.

Quarter: Check the appropriate quarter for which the company is submitting the report.

Item 5.

Quarterly Production Volume: Enter the number of gallons produced of this fuel for the quarter.

Item 6.

Fuel ID: Enter the EPA assigned fuel ID. Leave blank if you don't know this number.

Item 7.

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, use the first name listed on the "Fuel Manufacturer Notification for Motor Vehicle Fuel" EPA
Form 3520-12.

Item 8.

Additive Content: List of all US EPA registered additives previously reported for the fuel and their highest,
lowest,and average concentrations in milligrams per liter, even if usage was 0 in a particular quarter. If you are not
reporting in units of milligrams per liter, enter the concentration unit in which you are reporting in column (d). To have
an additive dropped from your listing, notify this office in writing.

Item 9.

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

Item 10. Assurance: 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

EPA Form 3520-12Q - Fuel Manufacturer Quarterly Report Instructions (11-2013)
company must provide a letter authorizing such agent.

OMB Control No. 2060-0150
Approval expires 10-31-16
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.

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