Form 3520-13A Fuel Additive Manufacturer Annual Report

EPA Form 3520-13A (11-01-2013) - Fuel Additive Manufacturer Annual Report

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

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

* Required Field

Leave Blank

Fuel Additive Manufacturer Annual Report

* 1a. Company ID:

* 1. Company Name:
* 2. Report Year: (Year format:YYYY)

* 3. Report Type: (Check Only One)
Original

Resubmission

4. For any additive below, do you have information, not previously reported, on the levels of impurities greater than 0.1 percent by
weight?
If "Yes," attach separate sheet(s) giving, to the extent known, the highest, lowest, and
Yes
No
average values of impurities, and the methods of analysis used.
5. For any additive below, do you have information, not previously reported, concerning the mechanisms of action of the additive;
reactions between the additive and gasoline and/or diesel fuel; the identification and measurement of the emission products
of the additive when used in gasoline and/or diesel fuel; the effects of the additive on all emissions; the toxicity and any
other public health or welfare effects of the emissions products of the additive; and/or 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.

6. Production Values:

a: Additive ID:

b. Market:
- Aftermarket
- Bulk
- Both

c: Production Volume:

d. Productions Units:
- Gallons (gal)
- Pounds (lb)
- Kilogram (kg)

EPA Form 3520-13A (11-01-2013) - Fuel Additive Manufacturer Annual Report

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* 7. 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 items 4, 5 and/or 6?
*

No

Yes

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

Item 4:

Yes

No

Item 5:

Yes

No

Item 6:

Yes

No

8. 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:

First Name:

Last Name:

* Telephone:

(

)

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