Form 3520-27 Load Port/Port of Entry Independent Sampling, Testing an

OMB 2060-0277 Expires XX/XX/XXXX (see instructions)

EPA

United States
Environmental Protection Agency
Washington DC 20460

Load Port/Port of Entry Independent Sampling,
Testing and Refinery/Importer Identification Form

1.0) Identifying Information

1.7) Name of Reporting Party

1.1) FormType
1.2) Report Type
1.3) Report Date

/
/

Load Port Form
Port of Entry Form
Original
Re-submission
1.5) Foreign Refinery Registration No.
(mm/dd/yy)

/
/

1.4) Date of Inspection (mm/dd/yy)

1.8) Name of Vessel

1.6) Importer Registration No.

1.9) Country of Registration of Vessel

2.0) Gasoline Volume (gallons)
2.1) Volume of Tank Bottoms
2.1.1) Prior to Loading

3.0) Vessel Departure/Arrival
3.1) Vessel Departure Date

2.2) Volume of FRGAS
2.2.1) Loaded onto Vessel

2.1.2) Prior to Unloading

3.2) Vessel Departure Time
3.3) Vessel Arrival Date

2.2.2) Unloaded from Vessel

3.4) Vessel Arrival Time

4.0) Foreign Refinery Gas (FRGAS) (check one)
5.0) Inspector

Certified

Non Certified

Diverted

5.1) Load Port Inspector Name

5.1.1) Identification No.

5.1.2) Date

5.2) Port of Entry Inspector Name

5.2.1) Identification No.

5.2.2) Date

6.0) Description of Method Used to Determine the Identity of the Refinery at which the Gasoline
was Produced

7.0) Certified FRGAS Volume Weighted Averages (7.1 - 7.2)
7.1.1) Sulfur (ppm)

7.1) Load Port

7.1.2) Benzene

7.1.3) API Gravity

.
7.2) Port of Entry

7.2.1) Sulfur (ppm)

7.1.4) E200

.

7.2.2) Benzene

.

7.2.3) API Gravity

.

7.1.5) E300

.

7.2.4) E200

.

7.2.5) E300

.

.

8.0) Certified FRGAS Values (8.1 - 8.2)
8.1) Load Port
8.1.1) RVP

.

8.1.2) Olefins 8.1.3) Aromatics

.

.

8.2) Port of Entry
8.2.1) RVP
8.2.2) Olefins 8.2.3) Aromatics

.

.

.

8.1.4) MTBE

.
8.2.4) MTBE

.

8.1.5) Ethanol

.
8.2.5) Ethanol

.

8.1.6) ETBE

8.1.7) TAME

.

.

8.2.6) ETBE

8.2.7) TAME

.

.

9.0) Comparison of Load Port and Port of Entry Emissions Performance Test Results
9.1) Load Port NOx Emissions (mg/mi)

9.3) Port of Entry NOx Emissions (mg/mi)

.
9.2) Load Port Exhaust Toxics Emissions (mg/mi)

.
Completed Forms are to be submitted
to the following address:
EPA Form 3520-27 (Rev. 06-99)

.
9.4) Port of Entry Exhaust Toxics Emissions (mg/mi)

.
U.S.E.P.A.
OECA Air Division
Attn: Jim Kellerstrass
12345 West Alameda
Suite 214
Denver, Colorado 80228

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OMB 2060-0277 Expires XX/XX/XXXX (see instructions)

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