OMB Control Number: 2060

- 0482

Expiration Date : 10 /31/1 4

EPA Form # 5900

- 140, Revised 5/11



### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE

EXPORT ER QUARTERLY REPORT



### ( 40 CFR 82. 13 )



## SECTION 1 EXPORTING COMPANY IDENTIFICATION

1.1 Date of Submi ssion 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 1 st 

### 2 nd 

### 3 rd 

### 4 th 

### 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 t

he 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; 10 th 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 with out further notice to the

company (40 CFR 2.203).

The public reporting and recordkeeping burden for this collection of inform ation 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 r espondent burden, including

throu gh the use of automated col lection 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 comple ted form to this address.OMB Control Number: 2060

- 0482

Expiration Date : 10 /31/1 4

EPA Form # 5900

- 140, Revised 5/11



### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE

EXPORTER QUARTERLY REPORT



### (40 CFR 82. 13 )



## SECTION 2 TRAN SACTION RECORD S

(Reproduce additional sheets as needed)

2.1 Company Name

2.2 Transaction Summaries

TRANSACTION #

Recipient Co mpany 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/y y) 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 UseOMB Control Number: 2060

- 0482

Expiration Date: 10 /31/ 1 4

EPA Form # 5900

- 140, Revised 5/11



### 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) Dest ruction (kg) Article 5 (kg) Quarantine and

Preshipment (QPS) (kg) Critical Use Exemption

(CUE) (kg) Emergency Use

Exemption (kg) Laboratory Use

Exemption (kg)

Total s