5900-140 Methyl Bromide Exporter Quarterly Report

OMB Control Number: 2060-0482

Expiration Date: 10/31/14

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance methyl bromide exporter quarterly report (40 CFR 82.13)

SECTION 1 EXPORTING COMPANY IDENTIFICATION

1.1 Date of Submission

     

1.2 Original Submittal Re-submittal

1.3 Number of Transactions Reported

     

1.4 Number of Pages Submitted

     

1.5 Quarter and Year to Which This Report Applies

1st

2nd

3rd

4th

Year      

1.6 Exporting Company

Company Name      

Street Address      

City      

State      

Zip Code      

Exporter EIN Number from Customs Form 7525:      

1.7 Company Contact Identification

Reporting Company Contact Person      

Phone Number      

Fax Number      

E-mail Address      

1.8 Signature of Reporting Company Representative

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      

Date      

SEND COMPLETED FORMS TO:

For U.S. Postal Service: Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenue, NW Washington, DC 20460

For Private Courier: Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1310 L Street, NW; 10th Floor Washington, DC 20005

A company may assert a claim of confidentiality for information submitted in this form by clearly marking that information as confidential. Such information shall be treated in accordance with EPA’s procedures for information claimed as confidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confidentiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2.203).

The public reporting and recordkeeping burden for this collection of information is estimated to average 1.3 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.

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance methyl bromide exporter quarterly report (40 CFR 82.13)

SECTION 2 TRANSACTION RECORDS (Reproduce additional sheets as needed)

2.1 Company Name

     

2.2 Transaction Summaries

TRANSACTION #

     

Recipient Company Name      

Street Address      

City      

Country      

Postal Code      

Company Contact Person      

Phone Number      

Fax Number      

Quantity of Methyl Bromide Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Purpose of export is for:

Transformation Destruction

QPS Critical Use

Emergency Use Article 5 Allowances

Lab Use

TRANSACTION #					     
Recipient Company Name      				Street Address      
City      				Country      					Postal Code      
Company Contact Person      				Phone Number      					Fax Number      
Quantity of Methyl Bromide Exported (kg)      		Date of Export (mm/dd/yy)      						Port of Export from the U.S.      
Purpose of export is for:	Transformation Destruction		QPS Critical Use			Emergency Use Article 5 Allowances				Lab Use

TRANSACTION #					     
Recipient Company Name      				Street Address      
City      				Country      					Postal Code      
Company Contact Person      				Phone Number      					Fax Number      
Quantity of Methyl Bromide Exported (kg)      		Date of Export (mm/dd/yy)      						Port of Export from the U.S.      
Purpose of export is for:	Transformation Destruction		QPS Critical Use			Emergency Use Article 5 Allowances				Lab Use

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance methyl bromide exporter quarterly report (40 CFR 82.13)

SECTION 3 COMPANY EXPORT TOTALS (Reproduce Additional Sheets as Needed)

3.1 Company Name

     

3.2 Transaction Summaries for Methyl Bromide

Country Exported To

Quantity of Methyl Bromide Exported (kg) Commodity Code 2903.30.1520

Transformation (kg)

Destruction (kg)

Article 5 (kg)

Quarantine and Preshipment (QPS) (kg)

Critical Use Exemption (CUE) (kg)

Emergency Use Exemption (kg)

Laboratory Use Exemption (kg)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Totals

     

     

     

     

     

     

     

EPA Form # 5900-140, Revised 5/11