OMB Control Number: 2060-0170

Expiration Date: 11/30/08

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<td colspan="5"><p><img src="media/image1.png"
style="width:0.56944in;height:0.26181in" /> U.S. Environmental
Protection Agency</p>
<blockquote>
<p><strong><span class="smallcaps">stratospheric ozone protection
program</span></strong></p>
</blockquote></td>
<td colspan="8"><p><span class="smallcaps">class i controlled
substance</span></p>
<p><strong><span class="smallcaps">distributor of qps<br />
methyl bromide quarterly report<br />
</span>(Sec 82.13)</strong></p></td>
</tr>
<tr class="even">
<td><strong>SECTION 1</strong></td>
<td colspan="12"><strong>DISTRIBUTOR IDENTIFICATION</strong></td>
</tr>
<tr class="odd">
<td><strong>1.1 Date of Submission</strong></td>
<td><strong>     </strong></td>
<td colspan="5"><blockquote>
<p><strong>1.2 Total Quantity of Methyl Bromide Delivered for Use in
Certified QPS Applications (kg)</strong></p>
</blockquote></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><p><strong>1.3</strong> <strong>Original
Submittal</strong></p>
<blockquote>
<p> <strong>Re-submittal</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="4"><strong>1.4 Quarter and Year to Which This Report
Applies</strong></td>
<td colspan="2"> 1<sup>st</sup></td>
<td colspan="3"> 2<sup>nd</sup></td>
<td colspan="2"> 3<sup>rd</sup></td>
<td> 4<sup>th</sup></td>
<td>Year <strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>1.5 Distributor Information</strong></td>
</tr>
<tr class="even">
<td colspan="13">Company Name <strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Street Address <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3">City <strong>     </strong></td>
<td colspan="5">State <strong>     </strong></td>
<td colspan="5">Zip Code <strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>1.6 Distributor Contact
Identification</strong></td>
</tr>
<tr class="even">
<td colspan="3"><p>Reporting Distributor Contact Person</p>
<blockquote>
<p><strong>     </strong></p>
</blockquote></td>
<td colspan="7"><p>Phone Number</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>Fax Number</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="13">E-mail Address      </td>
</tr>
<tr class="even">
<td colspan="13"><strong>1.7 Supplier Identification</strong></td>
</tr>
<tr class="odd">
<td colspan="13">Supplier Name <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="13"><strong>1.8 Signature of Reporting Distributor
Representative</strong></td>
</tr>
<tr class="odd">
<td colspan="13"><p><em>I certify that the total quantity of methyl
bromide listed in this form was exclusively sold for use in quarantine
&amp; preshipment applications, and not sold/ transferred to another
person.</em></p>
<p><em>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.</em></p></td>
</tr>
<tr class="even">
<td colspan="8"><p>Name <strong>     </strong></p>
<p>Title <strong>     </strong></p>
<p>Signature <strong>     </strong></p></td>
<td colspan="5">Date <strong>     </strong></td>
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+--------------------------+--------------------+---------------------+
| **SEND COMPLETED FORMS   | **For U.S. Postal  | **For Private       |
| TO:**                    | Service:**         | Courier:**          |
|                          |                    |                     |
|                          | Tracking System    | Tracking System     |
|                          | Program Manager    | Program Manager     |
|                          |                    |                     |
|                          | Stratospheric      | Stratospheric       |
|                          | Protection         | Protection Division |
|                          | Division           |                     |
|                          |                    | U.S. EPA -- (6205J) |
|                          | U.S. EPA (6205J)   |                     |
|                          |                    | 1310 L Street, NW;  |
|                          | 1200 Pennsylvania  | 10^th^ Floor        |
|                          | Avenue, NW         |                     |
|                          |                    | Washington, DC      |
|                          | Washington, DC     | 20005               |
|                          | 20460              |                     |
+--------------------------+--------------------+---------------------+

Information in reports submitted in compliance with the final rule may
be claimed as confidential. A company may assert a claim of
confidentiality for information submitted 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 16 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.

EPA ICR NUMBER 2179.03, Revised 1/07