OMB Control No. 2070

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1 

## United States Environmental Protection Agency

Instructions for Completing EPA Form 3540

- 16 Pesticide Report for Pesticide

- Producing and Device

- Producing Establishments Reporting Year 20 10

It is unlawful to knowingly falsify all or part of any pesticide or device production information reported on EPA Form 3540

- 16. (FIFRA § 12(a)(2)(M) )



### General Information

Read all instructions before completing this form. Type or print clearly in dark ink. This form may also be filled out and printed on

- line. Page one has space to enter one product. Use the “Add additional page” button at the bottom of the on

- line screen

- fillable form and add as many pages as necessary to report all products. Each “Additional” page has space for four (4) products. Please make sure you number each page. If you add too many pages, click the “Remo ve Extra Page” button to remove the last page added. See the Pesticide Establishment Registration and Reporting w eb page for
the instructions and the form. http://ww w.epa.gov/compliance/monitoring/programs/fifra/establishments.html

1. Who must report ?

**•** All domestic and foreign producing establishments, regardless of whether or not the establishment produced or distributed a pesticide, active ingredient or device must s ubmit a report. (FIFRA §§ 7 and 17)

**•** Establishments with zero production or distribution in 20 10 . If your establishment did not produce or distribute products subject to this report in 20 10 :

o Complete Items 1

- 27 and Items 40

- 43

.

o Check “ No ” in Item 14

.

**•** Establishments that closed, went out of business or ceased production.

o Report all production and distribution during 20 10

.

o See Number 7 for information on terminating your establishment’s registration

.

2. Definitions

o Producer

— any person, as defined by FIFRA, “who produces any pesticide, active ingredient, or device (including packaging, repackaging, labeling and relabeling).” ( 40 CFR §167.3)

o Produce

— “manufacture, prepare, propagate, compound or process any pesticide, including any pesticide product pursuant to FIFRA §5, any active ingredient or device, orOMB Control No. 2070

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2 to package, repackage, label, relabel or otherwise change the container of any pesticide or device.” (40 CFR §167.3)

o Establishment

— Includes:

o A ny site where a pesticidal product, active ingredient or device is produced.

o Sites that are independently owned or operated regardless of whether such site is domestic and producing a pesticidal product for export only or whether the site is foreign and producing a pesticidal product for import into the United States. (40 CFR §167.3)

o Sites that produce a pesticidal product for use under an Experimental Use Permit,

FIFRA Se ction 18 Emergency Exemption or S ection 24(c) Special Local Needs registration, must report. (40 CFR §167.20)

o Sites that produce unregistered pesticidal products for expor t from the US.

o Custom Blender

— any establishment that provides the service of mixing registered pesticides to a customer’s specifications, specifically:

o a pesticide

- pesticide blend

o a pesticide

- fertilizer blend

o a pesticide

- animal feed mixture

when

o the blend is not held in inventory

o the pesticide used in producing the blend bears labeling that does not prohibit the use of the pesticide in the blend

o the blend is delivered to the end

- user with a copy of the labeling of the pesticide used in p roducing the blend and a statement specifying the composition of the mixture

If these conditions are not met, the establishment does not meet the definition of "custom blender" and must comply with FIFRA Section 7 requirements.

3. What must be reported?

**•** Each producer operating an establishment must submit the following information for each pesticide

, active ingredient or device produced at your establishment: (Please note that production and distribution of unregistered pesticides must be reported. See 40 CFR § 152.30).

o Types and amounts produced in 20 10

.

o Types and amounts sold or distributed in 20 10

, regardless of when the product was produced.

o An estimate of the amount expected to be produced in 20 11

. NOTE: A facility where only custom blending activities take place is not considered a pesticide

- producing establishment and therefore does not need to be registered. Please see the Pesticide Establishment Registration and Reporting FAQ for more information. http://www.epa.gov/compliance/resources/monitoring/fifr a/faqestablishment.htmlOMB Control No. 2070

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3 **•** DO NOT REPORT :

o Production, distribution or sale of products NOT prod uced or repackaged by your establishment (e.g., no changes are made to the product formulation, container or label).

o Products shipped from your supplier directly to your customer.

o Any products for which Item s 36

, 37 and 38 are zero.

o Pesticides that are applied by your staff.

o R eturned inventory or carryover product from a previous year.

o Custom

- blended products

.

4. When to report:

**•** Annual Reports are due: On or before March 1, 20 11 , even if there has been no production

.

**•** I nitial Reports: FIFRA § 7 requires all registered establishments to submit a n initial report to the
U.S. EPA 30 days after receipt of notification of establishment registration. Failure to file the i nitial report is an unlawful act and may result in termination of the establishment’ s registration or your ability to import into the United States until you have fulfilled your reporting responsibility

.

5. Completing the Report:

**•** Enter the company official’s or authorized agent’s Name and Title (Items 40 & 41).

**•** An original signature of a company official or authorized agent is required on the report in Item 42.

**•** E nter the date in Item 43.

**•** For all pages complete at the bottom: “This is Page _____ of _____.”

**•** Submit completed reports as directed on Page 9 . Please make a copy of the r eport for your record s

.

**•** EPA will not accept any copies (xeroxed, faxed or electronic document formats) of the initial or annual reports (EPA Form 3540

- 16).

6. What if I fail to file this production report?

Failure to file an initial or annual production report is a violation of FIFRA, and may result in termination of the establishment’s registration, civil penalties up to $ 7 ,500 per violation and/or criminal penalties. It may also affect your ability to import until you are in compliance.

7. How to terminate your establishment’s registration :

**•** Send a letter on company letterhead with th is report stating the establishment is out of business or has ceased production of pes ticides , active ingredients or devices requesting that

your establishment number be terminated

.

**•** If EPA terminates your domestic establishment registration, it is illegal to sell or distribute any pesticide , active ingredient or dev ice in the United States or to export a product out of the United States. If EPA terminates your foreign establishment registration, it is illegal for you to import any pesticide , active ingredient or device into to the United States.OMB Control No. 2070

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4 8. Additional Inform ation is available at Pesticide Establishment

— Registration and Reporting Questions at: http://www.epa.gov/compliance/resources/monitoring/fifra/faqestablishment.html

.



### General Instructions

Establishment Information : ( Item s 1 through 14)

**•** Item 1

— Establishment Name : E nter the producing establishment name.

**•** Item 2

— Establishment Number : E nter the producing establishment number.

**•** Item 3 to 6

— Establishment Site Address : E nter the SITE address

, not a post office box or
route number , where your establishment is located. For foreign establishments, zip code is equivalent to postal code, post c ode or postcode

.

**•** Item 7 to 10

— Establishment Mailing Address : Enter the mailing address for the
establishment if different from the site address.

**•** Item 11

— Telephone Number : Enter the phone number for the establishment. For foreign establishments, please provide the country code.

**•** Item 12

— Em ail : Enter your e m ail address.

**•** Item 13

— If the establishment name or site address has changed from the previous year, enter a check ( X ) in the box.

**•** Item 14

— Did you produce or distribute in 20 10 ? Check the appropriate box. Note: If you checked the “No” box, do not fill in items 28 through 39.

Company Information : ( Item s 1 5 through 27 )

**•** Item 15

— Company Name : E nter the company name

.

**•** Item 16 to 19

— Company Site Address : E nter the company ’s headquarter address

.

**•** Item 20 to 23

— Company Mailing Address : Enter the mailing address for the company if
different from the company site address.

**•** Item 24

— Telephone Number : Enter the phone number for the company. For foreign

compan ies , please provide the country code.

**•** Item 25

— Em ail : Enter your e m ail address

.

**•** Item 26

— If company name or site address has changed from the previous year, enter a check ( X ) in the box.

**•** Item 27

— If Authorized Agent name or mailing address has changed from the previous year, enter a check ( X ) in the box. Please attach your company’s request to change the authorized agent on company letterhead and send to the appropriate EPA office listed on Page 9

. NOTE: For items 5, 9, 18 and 22

— Foreign country abbreviation codes are available at: http://www.epa.gov/compliance/resources/publications/monitoring/fifra/fgnestablishments.html
Please contact U.S. EPA Headquarters 011

- 202

- 564

- 4203 if you do not see the appropriate country code listed

. http://www.epa.gov/compliance/resources/monitoring/fifra/faqestablishment.htmlOMB Control No. 2070

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5 Pesticide Production Information : ( Item s 28 through 39 )

**•** Item 28

— Product Code :

o Enter 1

— if product is registered with EPA

.

o Enter 2

— if product registration is pending.

o Enter 3

— if product is an Experimental Use Permit.

o Enter 4

— if product is a device

.

o Enter 5

— if product is a Special Local Need (SLN) registration. “Special Local Need (SLN)” means an existing or imminent pest problem within a State for which the State lead agency, based upon satisfactory supporting information, has determined that an appropriate federally registered pesticide product is not sufficiently available. (See: EPA regulations at 40 CFR §162.151)

o Enter 6

— if product is an Unregistered Pesticide. Attach the formulation of the product to the end of the report showing the product’s active and inert ingredients; their common names; their CAS Regi stry numbers (if available); and the percentage, by weight, of each ingredient (must total 100%). Multiple formulations may appear on the same page; clearly identify each by product name.

**•** Item 29

— EPA Product Registration Number Information :

o Produ ct Code 1

— Enter EPA Registration No. (as it appears on product label) (See NOTE b elow on reporting production of multiple distributor registrations).

o Product Code 2

— Enter EPA File Symbol assigned to product

.

o Product Code 3

— Enter the Experimental U se Permit number.

o Product Code 4

— For devices

, leave Item 29 blank.

o Product Code 5

— For stand

- alone SLN Registrations

, enter the SLN registration number in Item 29 (e.g., SLN

- CA

- 890022). A “ stand

- alone ” SLN is one for
which there a re no uses other than the 24(c) uses.

o Product Code 6

— For Unregistered Pesticides

, leave Item 29 blank. NOTE: Foreign Establishments

– You must report production for products exported to or
marketed in the United States. If your establishment produced a pesticide, active ingredient or device and sold some of the product in countries other than the United States, do not report this portion of your production and distribution. For example, if you produce 10,000 pounds of a product and sell 9,000 to other countries and 1,000 pounds to the United States; you should report 1,000 produced and 1,000 distributed.OMB Control No. 2070

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6 **•** Item 30

— Product Name :

List the most common brand name. If marketed under alternate brand names, add the wording

“ and alternate brand names ” or “ ABN ” and report total production under all names for the formulation.

**•** Item 31

— Product Classifications : Enter the code that best describes the product’s use.

o Classification for Devices
51 Device

o Classifications for Pesticides
0 4 Insect Repellant 0 7 Antimicrobial 0 9 Attractant
18 Sterilizer 20 Disinfectant 21 Sanitizer
27 Fungicide 28 Nematocide 29 Fumigant
34 Herbicide 36 Defoliant 37 Desiccant
38 Antifoulant 43 Insecti cide 49 Plant Growth Regulator
54 Rodenticide 57 Animal Repellant 59 Algaecide
61 Molluscicide (e.g. slug bait) 69 Water Purifier

99 Multi

- Use Active Ingredient (Chemicals that have both pesticidal and non

- pesticidal uses). These chemicals do not have an EPA Reg. No. (This classification is rarely appropriate. Producers are required to register both the product and their establishment(s) and report production on an annual basis under FIFRA § 7

, if a producer has actual or constructive knowledg e that a chemical or substance they produce is used or intended for use as an active ingredient in the manufacture of a pesticide. These producers are required to report only the amount of the chemical or
substance manufactured and distributed or sold for pesticidal purposes.

**•** Item 32

— Product Type :

o Enter 1

— Technical formulations or active ingredient for Manufacturing Use Only products

.

o Enter 2

— End

- use product (this includes products where the formulation has been blended, diluted, or changed)

.

o Enter 3

— Repackaged or relabeled (does not include any blending, dilution or change in the formulation)

.

o Enter 4

— Device

. NOTE: Reporting Distributor Registrations

— If you produce multiple pesticide products
under the same basic EPA registration number (such as distributor products):

Report the total quantities for all distributor products under the basic EPA registration number, and following the product name add “and supplementals.” On a separate paper, list the basic registration number with each distributor company number and brand name and attach it to the report.OMB Control No. 2070

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7 **•** Item 33

— Market Sold or Distributed To :

o Enter 1

— if all the product was marketed in the United States.

o Enter 2

— if the product was marketed both in the United States and exported from the
United States.

o Enter 3

— if all the product was exported from the United States

.

**•** Item 34

— RUP Status :

o Enter 1

— Product label states RESTRICTED USE PESTICIDE at the top of the front
label panel.

o Enter 2

— All other products

.

**•** Item 35

— Unit of Measurement :

o G = Gallons (liquid chemical product)

o K = Kilograms ( dry, solid , liquid or gaseous chemical product )

o L = Liters (liquid chemical product)

o P = Pounds ( dry, solid , liquid or gaseous chemical product )

o T = Tons (short ton = 2,000 lbs. or 907.2 kilograms) ( dry, solid or gaseous chemical product )

o U = Units (devices and pesticides that the label does not declare as gallons, pounds, liters, kilograms or tons)

**•** Item 36

— Amount Produced in 20 10 :

o Do not include amounts that are custom blended or applied to a crop, commodity or site by your staff.

o Round all quantities to the nearest whole number

.

**•** Item 37

— Amount Sold or Distributed in 20 10

- United States :

o Enter only those products sold or distributed that were produced by your establishment, regardless of when the product was produced.

o Do not include amounts that are custom blended or applied to a crop, commodity or site by your staff.

o Foreign producers should enter only the amount of product or number of devices exported
to the United States.

o Round all quantities to the nearest whole number

.

**•** Item 3 8

— Amount Sold or Distributed in 20 10 to Foreign Markets (Exported):

o Enter the quantity exported from the United States in 20 10 , regardless of when the product was produced.

o Round all quantities to the nearest whole number

.

o Foreign establishments enter “0” in Item 3 8

.OMB Control No. 2070

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8 **•** Item 3 9

— Amount (Estimated) to be Produced in 20 1 1 :

o Enter an estimate of the quantity to be produced in 20 1 1

.

o Round all quantities to the nearest whole number

.

Signature Certification : ( Item s 40 through 43 )

**•** Item s 40 and 41

— Name and Title of Company Official or Authorized Agent : Please enter the name and title of the person who is responsible for your establishment ’s compliance with the requirements of FIFRA § 7. Note: If you are the authorized agent submitting this report

, please enter your name and title.

**•** Item s 42 and 43

— Signature of Company Official or Authorized Agent : The company official and/or authorized agent listed in Item 40 must sign and date the report in order for it to
be complete

.

Confidentiality. Under FIFRA §7(d) [7 USC §136e], information reported in Ite m s 36, 37, 38 and 39
of EPA Form 3540

- 16 will be treated as business confidential, subject to the provisions of FIFRA §10 [7 USC §136h]. You are not required to assert a claim of confidentiality for this information.

If you wish to assert a claim of conf identiality for other information you have provided on this form, you must identify by the box number(s) information for which you are asserting a claim of confidentiality. Information so designated will be disclosed by the EPA only to the extent allowed by, and by means of, the procedures set forth in 40 CFR Part 2. If you do not claim the information as confidential upon submission of the report, it may be made available to the public without further notice to you.

Public Reporting Burden. The time re quired to complete this report is estimated to average one hour and 26 minutes, per response, including reviewing instructions, searching data sources, gathering and maintaining data needed, and completing review and collection of information. Send commen ts regarding this burden estimate or other aspects related to this information collection, including suggestions for reducing this burden, to: Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, DC 20460. Include the OMB control number in any correspondence. Do not send the completed 3540

- 16 form to the above
address.OMB Control No. 2070

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9 

## Where to Submit Reports

DOMESTIC PRODUCERS: Submit reports to the following EPA Regional Office where your c ompany headquarters is located.

FOREIGN PRODUCERS : Submit reports to the following EPA Washington, DC address:

U.S. Postal Service Mail Address

Michelle Stevenson U.S. Environmental Protection Agency Agriculture Division (2225A) 1200 Pennsylvania Avenue, NW Washington, DC 20460

- 0001 USA Telephone: 202

- 564

- 4203 Courier Delivery Address

Michelle Stevenson U.S. Environmental Protection Agency Agriculture Division Ariel Rios Building

-- South 1200 Pennsylvania Avenue, NW, Room 6102 Washington, DC 20004 USA

NOTE: The Agency does not notify you when your r eport is received. To ensure the Agency receives the report, you may wish to send it by certified or registered mail, return receipt requested. EPA Regional Offices States/Terr. Covered EPA Regional Offices States/Terr. Covered

U.S. EPA Region 1
Kan Tham
Toxics and Pesticides Unit ( OES 05

- 4) 5 Post Office Square, Suite 100 Boston, MA 02109

- 3912 Telephone: 617

- 918

- 1872 CT, MA ME, NH RI, VT U.S. EPA Region 6 Chuck Ruple Pesticides Section (6PD

- P)
1445 Ross Avenue Dallas, TX 75202

- 2733 Telephone: 214

- 665

- 6 534 AR, LA NM, OK
TX

U.S. EPA Region 2
Michael Kramer Pesticides Team (MS

- 500) 2890 Woodbridge Avenue Edison, NJ 08837

- 3679 Telephone: 732

- 321

- 6610 NJ, NY PR, VI U.S. EPA Region 7 Delbert Kelley Pesticides Section (WWPD/TOPE/PEST) 901 N. 5th Street Kansas City, KS 66101

- 2798 Telephone: 913

- 551

- 7371 IA, KS MO, NE

U.S. EPA Region 3 Kyla Townsend

- McIntyre
Pesticides and Asbestos Programs Branch (3LC62)
1 650 Arch Street Philadelphia, PA 19103

- 2029 Telephone: 215

- 814

- 2045 DC, DE MD, PA VA, WV U.S. EPA Region 8 Kathleen Craig Enforcement Division ( 8ENF

- PJ) 1595 Wynkoop Denver, CO 80202 Telephone: 303

- 312

- 6049 CO, MT ND, SD UT, WY

U.S. EPA Region 4 Mary Summers
Chemical Products & Asbestos Section 61 Forsyth Street, SW 12 th Floor Atlanta, GA 30303 Telephone: 404

- 562

- 8997 AL, FL GA, KY MS, NC SC, TN U.S. EPA Region 9 Glenda Dugan Pesticides Office (CED

- 5) 75 Hawthorne Street San Francisco, CA 94105

- 3901 Telephone: 415

- 947

- 4204 AZ, CA GU, HI
MP

, NV

U.S. EPA Region 5
Gail Muffitt PTCS ( LC

- 8J )
77 W. Jackson Blvd. Chicago, IL 60604

- 3507 Telephone: 312

- 886

- 6008 IL, IN MI, MN OH, WI U.S. EPA Region 10
Erin Halbert
Pesticides and Toxics Unit (OCE

- 084) 1200 Sixth Avenue, Suite 900 Seattle, WA 98101

- 1128 Telephone: 206

- 553

- 4627 AK, ID OR, WA