5900-139 Certification of Purchase of Critical Use Methyl Bromide

OMB Control Number: 2060-0170
Expiration Date: 4/16/2023

CLASS I CONTROLLED SUBSTANCE
METHYL BROMIDE

U.S. Environmental Protection Agency
STRATOSPHERIC OZONE PROTECTION PROGRAM

CERTIFICATION OF PURCHASE OF CRITICAL
USE METHYL BROMIDE (40 CFR 82.13)

SECTION 1 PURCHASER INDENTIFICATION
1.1 Date of Submission
1.2 Total Quantity of New Production Pre-Plant Critical Use Methyl Bromide Purchased (kg)
1.3 Total Quantity of New Production Post Harvest Critical Use Methyl Bromide Purchased (kg)
1.4 Company Information
Company Name
Street Address
City

State

Zip Code

1.5 Company Contact Identification
Reporting Company Contact Person
E-mail Address
Phone Number

Fax Number

Approved critical use(s) are those uses of methyl bromide listed in Appendix L to Subpart A of 40 CFR Part 82. See
www.epa.gov/ozone/mbr/cueuses.html.

1.6 Signature of Reporting Company Representative
I certify, under penalty of law, that the quantities of methyl bromide specified in Section 1.2 and 1.3 of this form, are ordered/purchased
and will be sold or used exclusively for an approved critical use (pre-plant or post-harvest) as identified, and not sold/ transferred to
another person. I certify that I am an approved critical user and I will use this quantity of methyl bromide for an approved critical use. My
action conforms to the requirements associated with the critical use exemption published in 40 CFR part 82. I am aware that any
agricultural commodity within a treatment chamber, facility or field I fumigate with critical use methyl bromide cannot subsequently or
concurrently be fumigated with non-critical use methyl bromide during the same control period, excepting a QPS treatment or treatment for
a different use (e.g., a different crop or commodity). I will not use this quantity of methyl bromide for a treatment chamber, facility, or field
that I previously fumigated with non-critical use methyl bromide during the same control period, excepting a QPS treatment or treatments
for a different use (e.g., a different crop or commodity), unless a local township limit now prevents me from using methyl bromide
alternatives or I have now become an approved critical user as a result of rulemaking.
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 Critical Use Methyl Bromide Is
Being Purchased

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0170). Responses to this collection
of information are mandatory (40 CFR 82.13). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The number and expiration date are displayed in the upper right corner of the form. The public reporting and recordkeeping
burden for this collection of information is estimated to be 1 hour per response. Send comments on the Agency’s need this formation, 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, Regulatory Support
Division, U.S. Environmental Protection Agency (2821T), 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 # 5900-139, Revised 8/18