OMB Control Number: 2060-0482

Expiration Date: 10/31/14

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 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 1

st 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.

 
OMB Control Number: 2060-0482

Expiration Date: 10/31/14

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 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
OMB Control Number: 2060-0482

Expiration Date: 10/31/14

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) Destruction (kg) Article 5 (kg) Quarantine and 

Preshipment (QPS) (kg)

Critical Use Exemption 

(CUE) (kg)

Emergency Use 

Exemption (kg)

Laboratory Use 

Exemption (kg)

Totals