5900-154 QPS Certification

OMB Control Number:
2060-0170 Expiration Date:
8/31/21

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

CERTIFICATION OF ORDER/PURCHASE
OF QPS METHYL BROMIDE

STRATOSPHERIC OZONE PROTECTION PROGRAM

(Sec 82.13)

SECTION 1

PURCHASER IDENTIFICATION AND METHYL BROMIDE USE

1.1 Date of
Submission

1.2 Quantity of Methyl Bromide Ordered/ Purchased
(kg)

1.3 Company Information
Purchaser Name
Street Address

City

State

Zip Code

1.4 Company Contact Identification
Reporting Company Contact Person

Phone Number

Fax Number

E-mail Address
Quarantine Applications, with respect to Class I, Group VI controlled substances (methyl bromide), are treatments to prevent the
introduction, establishment and/or spread of quarantine pests (including diseases), or to ensure their official control, where: (1) Official
control is that performed by, or authorized by, a national (including state, tribal or local) plant, animal or environmental protection or health
authority; (2) quarantine pests are pests of potential importance to the areas endangered thereby and not yet present there, or present
but not widely distributed and being officially controlled. This definition excludes treatments of commodities not entering or leaving the
United States or any State (or political subdivision thereof).
Preshipment Applications, with respect to Class I, Group VI controlled substances (methyl bromide), are those non-quarantine
applications applied within 21 days prior to export to meet the official requirements of the importing country or existing official
requirements of the exporting country. Official requirements are those which are performed by, or authorized by, a national plant, animal,
environmental, health or stored product authority.

1.5 Signature of Reporting Company Representative
I certify that the quantities of methyl bromide specified in Section 1.2 of this form are ordered/purchased and will be used exclusively for
quarantine & preshipment applications as defined above, and not sold/ transferred to another person. I certify under penalty of law that I
have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my
inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate,
and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
Name
Title
Signature

SEND COMPLETED FORMS TO:

Date

The Company from Whom the
Methyl Bromide is Being Ordered/Purchased

The public reporting and recordkeeping burden for this collection of information is estimated to average 2.1 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. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA Form # 5900-154, Revised 8/18