OMB Control Number: 2060-0482

 Expiration Date: 6/30/15

EPA Form # 5900-142, Revised 7/14

 

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE

PRE-2005 STOCKS ANNUAL REPORT

(40 CFR 82.13)

NOTE: FORM MUST BE COMPLETED BY ANY COMPANY THAT OWNS STOCKS OF METHYL BROMIDE THAT WERE PRODUCED OR IMPORTED 

PRIOR TO JANUARY 1, 2005.

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission 1.2 Year to Which This Report Applies

1.3 Original Submittal Re-submittal

1.4 Company Information

Company Name 

Street Address 

City State Zip Code 

1.5 Company Contact Identification

Reporting Company Contact Person 

E-mail Address 

Phone Number Fax Number 

1.6 Company Type 

(check all that apply) Distributor Third Party Applicator Producer Importer

1.7 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:

U.S. EPA

Stratospheric Protection Division

Office of Atmospheric Programs

Mail Code: 6205T

1200 Pennsylvania Avenue, NW

Washington, D.C. 20460

For Private Courier:

U.S. EPA

Stratospheric Protection Division

Office of Atmospheric Programs

Room 4355CC

1201 Constitution Avenue, NW

Washington, D.C. 20004

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: 6/30/15

EPA Form # 5900-142, Revised 7/14

 

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE

PRE-2005 STOCKS ANNUAL REPORT

(40 CFR 82.13)

SECTION 2 TRANSACTION DATA

2.1 Company Name

2.2 Total Stocks of Pre-Phaseout Methyl Bromide*

kg

Owned by reporting company as of December 31 of this year (including all quantities owned by reporting 

company that are held by other suppliers on the reporting company’s behalf)

* These quantities of stocks refer only to amount of methyl bromide that were produced or imported before January 1, 2005. Any quantities 

of newly produced critical use methyl bromide left in the reporting company’s possession as of December 31 of this year should be reported 

on form “Sales of Critical Use Methyl Bromide,” section 2.3.

2.3 Name(s) of Company(ies) which are Holding Stocks of Pre-Phaseout Methyl Bromide on Behalf of the Owner

Company Name: Amount Held (kg): 

Company Name: Amount Held (kg): 

Company Name: Amount Held (kg):