Form 3520-13 Fuel Additive Manufacturer Notification

EPA Form 3520-13 (11-01-2013)- Fuel Additive Manufacturer Notification

Page 1 of 6
Form Approval
OMB No. 2060-0150
Approval Expires 10/31/2016

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

* Required Field

Leave Blank

Fuel Additive Manufacturer Notification

* 1. Additive (Commercial Name):
*

* 2. Company Name:

New Company

2a. Company ID:

Registered Company

* 3. Street Address:
* City:

* Zip:

* Province:

* State:

* Country:

* 4. Method of Use (Check as Appropriate):
Bulk Treatment - Blended into fuel prior to being dispensed into a vehicle.
Aftermarket - Sold in consumer-sized containers for addition to a vehicle's fuel system.
5. Recommended Usage and Range of Concentration
(Complete as appropriate. If this is an aerosol, only indicate the recommended frequency of use)
Bulk Treatment
For Use In

Range of Additive Concentration
) Unit

(
Highest

Lowest

Aftermarket
For Use In

Range of Additive Concentration

)

(

Average

Highest

Unleaded Motor
Vehicle Gasoline

Unleaded Motor
Vehicle Gasoline

Motor Vehicle
Diesel Fuel

Motor Vehicle
Diesel Fuel

Lowest

Unit

Average

If this is an aerosol, recommended frequency of use:
6. Recommended Purpose-In-Use of the fuel additive named in Item 1 (Check Appropriate Item(s)).
Purpose-In-Use
Gas Diesel
Gas Diesel
Purpose-In-Use

(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)
(r)
(s)
(t)
(u)
(v)
(w)
(x)
(y)

Anti-icing agent/moisture absorbent
Antiknock
Antioxidant
Antistall agent
Antistatic agent
Cetane improver
Combustion improver/modifier
Corrosion inhibitor
Deposit modifier/control
Detergent
Dye
Gum solvent
Masking or odorizing agent
Metal deactivator
Pour point depressant
Sediment inhibitor
Stabilizer or dispersant
Upper cylinder lubricant
Octane enhancer
Flow improver
Volume extender
Carburetor and choke cleaner
Algaecide/bactericide/fungicide
Valve lubricant
Demulsifier/dehazer

(ac)
(af)
(an)
(bc)
(bd)
(ca)
(cc)
(cp)
(dc)
(df)
(di)
(ec)
(es)
(fr)
(ia)
(ic)
(iv)
(la)
(mr)
(ox)
(pc)
(ri)
(sf)
(sw)
(tr)
(sc)

Additive component
Anti-flamant
Acid neutralizer
Blended component/blend stock
Biodiesel
Carrier
Combustion chamber cleaner
Cloud point depressant
Detergent compound
Defoamer
Dilutent
Emission control
Exhaust system cleaner
Certified detergent
Identifying agent
Fuel injector cleaner
Intake valve cleaner
Lubricity agent
Marker
Oxygenate
Process chemical
Rust inhibitor
Starting Fluid
Sweetener
Tracer
Scavenger

EPA Form 3520-13 (11-01-2013)- Fuel Additive Manufacturer Notification

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* 7. Chemical Composition:

Component
Percent

(a) Names of Additive Compounds or Components

Methods of
Analysis

Elemental
Percent

(b) Elemental Breakdown

(c) Information on the chemical process of manufacturer is attached.

Yes

Chemical Abstract
Service No.

Methods of
Analysis

No

8. Chemical Structure - Is the chemical structure of all components completely defined by the names given under Item 7(a)?

*

Yes

No

If "No," attach separate sheet(s) providing the complete structures of such components, so far as they are known.

Yes

No

Does this Additive use Nanotechnology?

9. Impurities - If greater than 0.1% by weight, to the extent known:
Percent by Weight
Name of Impurities

Highest

Lowest

Average

Methods of Analysis

EPA Form 3520-13 (11-01-2013)- Fuel Additive Manufacturer Notification

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* 10. Do you know of any analytical techniques that can be used to detect the presence of this fuel additive and/or measure its
concentration in gasoline and/or diesel fuel?
Yes

No

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

* 11. Do you have any information developed by or for you concerning the mechanisms of action of this fuel additive; reactions
between this fuel additive and gasoline and/or diesel fuel; the identification and measurement of the emission products of this fuel
additive when used in gasoline and/or diesel fuel; the effects of this fuel additive on all emissions; the toxicity and any other public
health or welfare effects of the emission products of this fuel additive; and/or the effects of the emission products on the performance
of emission control devices or systems?
No

Yes

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

* 12. Is this additive a relabel of an additive currently registered under 40 CFR section 79?
*

No

Yes

If "Yes," enter the name of the additive and its manufacturer.

Name of registered additive:
Manufacturer:
* 13. Annual Production - What is the estimated annual volume, in gallons, of this additive during the third year of production?
Bulk:

Gallons

Gallons

Aftermarket:

* 14. Market Distribution - To the nearest percent (no decimals), estimated for the third year of production, enter
the percent of sales by Petroleum Administration for Defense District (PADD) for the bulk additive volume and the
percent of sales for each state for the aftermarket additive volume.
Bulk:
PADD5

PADD2

PADD3

PADD4

IL

AL

CO

AK

DE

IN

AR

ID

AZ

DC

IA

LA

MT

CA

FL

KS

MS

UT

HI

GA

KY

NM

WY

NV

ME

MI

TX

MD

MN

MA

MO

NY

NE

NH

ND

NJ

OH

NC

OK

PA

SD

RI

TN

SC

WI

PADD1
Aftermarket:
CT

VT
VA

WV

OR

WA

EPA Form 3520-13 (11-01-2013)- Fuel Additive Manufacturer Notification

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If you answered "yes" to item 12, skip to item 19.
15. Is this fuel additive derived only from conventional petroleum, heavy oil deposits, coal, tar sands, and/or oil sands?
Yes

No

16. Small Business Provisions - 40 CFR 79.58(d).
A manufacturer of a baseline or non baseline additive 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 additive 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:

17. Aerosol - Is this an aerosol additive?

*

No

Yes

If "Yes," do you claim applicability of the special provisions for aerosol additives at 40 CFR 79.58(e)?
No

Yes

If "Yes," attach the information required for an aerosol additive and skip to item 19.

EPA Form 3520-13 (11-01-2013)- Fuel Additive Manufacturer Notification

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18. Grouping Information - Pursuant to 40 CFR section 79.56. If you do not qualify for an aerosol or Tier 1 and Tier 2 small business
exemption, you must be a member of a testing group appropriate for your fuel additive or supply the appropriate health-effects test
information.
This additive 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.

* 19. 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 item?
*

No

Yes

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

Item 5:

Yes

No

Item 10:

Yes

No

Item 14:

Yes

No

Item 7:

Yes

No

Item 11:

Yes

No

Item 15:

Yes

No

Item 8:

Yes

No

Item 12:

Yes

No

Item 16:

Yes

No

Item 9:

Yes

No

Item 13:

Yes

No

Item 18:

Yes

No

20. Attachments - Are attachments included with this notification?
No

Yes

If "Yes," list below:

No

Yes

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

EPA Form 3520-13 (11-01-2013)- Fuel Additive Manufacturer Notification

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21.Certification
To the best of my knowledge, the above is complete and correct.
I am authorized by the manufacturer to submit this notification.
As per 40 CFR 79.21(f), the U.S. Environmental Protection Agency would be notified in writing if certain information in this
notification were to change.
This fuel additive 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
additive constitutes endorsement, certification, or approval by any agency of the United States.

Signature:
* Date:
* Name of Signer
* Telephone:

Prefix:

(

)

Last Name:

First Name:
Fax:

Extension:

Title:

)

(

E-mail:

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

Prefix:

(

)

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