Form 3520-20b Reformulated Gasoline and Anti-Dumping Facility Regristr

OMB 2060-0277 expires 10/31/2007 (see instructions)

23698

EPA

United States
Environmental Protection Agency
Washington DC 20460

Gasoline Programs Facility Registration

1.0) Identifying Information
1.1) Registration Type (shade one)

Original

Update

1.2) Report Date (mm/dd/yy)

/

1.3) Company ID (see instructions)

/

1.4) Company Name

2.0) Facility Information
2.1 & 2.2) Facility Activity Types & EPA-Assigned Facility ID(s)
Refinery

Importer

Oxygenate Blender

RIN Generator (ethanol producer)

2.3) Facility Name

2.4) Facility Address 1

2.5) Facility Address 2

2.6) Facility City

2.7) Fac. State

2.8) Facility ZIP Code

2.9) Facility County

2.10) Facility Country

2.11) PADD

3.0) Contact Information
3.1) Contact Name

3.2) Contact Title

3.3) Contact e-Mail

3.4) Contact Phone

-

-

EPA Form 3520-20B (Rev. 04/2007)

3.5) Extension

3.6) Contact Fax

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Page 1 of 3

OMB 2060-0277 expires 10/31/2007 (see instructions)

23698

EPA

United States
Environmental Protection Agency
Washington DC 20460

Gasoline Programs Facility Registration

4.0) Record Storage Information
4.1) Records for this Facility are Stored (shade one)

On-Site

Off-Site

Both

If Records are Stored Off-Site or Both On-Site and Off-Site, then Complete the Remainder of this Section:
4.2) Off-Site Location

4.3) Off-Site Address 1

4.4) Off-Site Address 2

4.5) Off-Site City

4.6)State

4.7) Off-Site ZIP Code

4.8) Off-Site Contact Name

4.9) Off-Site Contact Title

4.10) Off-Site Contact e-Mail

4.11) Off-Site Contact Phone

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4.12) Extension

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4.13) Off-Site Contact Fax

-

-

5.0) Independent Laboratory Information (RFG/RBOB Refiners & Importers Only)
5.1) Independent Analysis Requirement Options(shade one option and/or "Exemption" - see instructions)

Option 1 (100%)

Option 2 (10%)

In-Line Blending Exemption

5.2) Approval Date of In-Line Blending Petion(mm/dd/yy)

/
5.3) Lab ID

/
5.4) Lab Name

5.5) Lab City

5.6) State

5.7) Lab ZIP Code

EPA Form 3520-20B (Rev. 04/2007)

Page 2 of 3

OMB 2060-0277 expires 10/31/2007 (see instructions)

23698

EPA

United States
Environmental Protection Agency
Washington DC 20460

Gasoline Programs Facility Registration

6.0) Certification
6.1) Responsible Corporate Officer or Business Owner Name

6.2) Responsible Corporate Officer or Business Owner Title

6.3) Responsible Corporate Officer or Business Owner e-Mail Address

The responsible corporate officer or business owner certifies that this Reformulated Gasoline and Anti-Dumping Facility Registration form is
true and correct and that this person is duly authorized to submit such reports to EPA.

6.4) Signature
6.5) Date Signed

/

Completed Forms are US Mail:
to be submitted to
one of the following
addresses.
EPA Form 3520-20B (Rev. 04/2007)

U.S. E.P.A.
Fuels Programs Registration
(6406J)
1200 Pennsylvania Avenue NW
Washington, DC 20460

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Commercial U.S. E.P.A.
Fuels Programs Registration
Delivery:

Room 647C; (202) 343-9038
1310 L Street, NW
Washington, DC 20005
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