Form 3520-20A Reformulated Gasoline and Anti-Dumping Company Registrat

33894

OMB 2060-0277 expires 10/31/2007 & OMB 2060-0308 expires 1/31/2008 (see instructions)

EPA

United States
Environmental Protection Agency
Washington DC 20460

1) Registration Type (shade one)

Original

Fuels Programs Company/Entity Registration

2) Report Date (mm/dd/yyyy)

/

Update

3) Company/Entity ID

/

4) Company/Entity Name
5) Company/Entity Address 1
6) Company/Entity Address 2
8) State

7) Company/Entity City

9) Company/Entity Zip Code

10) Contact Name
11) Contact Title
12) Contact e-Mail
13) Contact Phone

-

14) Extension

15) Contact Fax

-

-

-

16) Program Type 17) Business Activities (see instructions)

Gasoline
Diesel
RFS

Refiner
Importer
Biodiesel Producer
Transmix

Oxygenate Blender
Independent Lab
RIN Generator (ethanol)

Pipeline/Pass-Through Terminal
Mobile Facility
Truck Loading Terminal
RIN Owner (Other than Generator &
Obligated Party)

18) Responsible Corporate Officer or Business Owner Name
19) Responsible Corporate Officer or Business Owner Title
20) Responsible Corporate Officer or Business Owner e-Mail Address

The responsible corporate officer or business owner certifies that this registration form is true and correct and that this person is duly
authorized to submit such reports to EPA.

21) Signature

EPA Form 3520-20A (Rev. 04-2007)

See instructions for mailing
information
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