OMB Control No. 2070

- 0078 Expires on 3/31/2016

1 

## United States Environmental Protection Agency

Instructions for Completing EPA Form 3540

- 16 Pesticide Report for Pesticide

- Producing and Device

- Producing Establishments Reporting Year 201 3

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 on
- line and printed. 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. If you add too many pages, click the “Remove 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://www.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 di stributed a pesticide, active ingredient or device must submit a report. (FIFRA §§ 7 and 17)

 Establishments with zero production or distribution in 201 3 . If your establishment did not produce or distribute products subject to this report in 201 3 :

o Complete Items 1

- 35 and Items 36

- 39

.

o Check “ No ” in Item 1 8

.

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

o Rep ort all production and distribution during 201 3

.

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, or to packa ge, repackage, label, relabel or otherwise change the container of any pesticide or device.” (40 CFR §167.3)OMB Control No. 2070

- 0078 Expires on 3/31/2016

2 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 facility 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 producing the blend and a statement specify ing 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 2013

.

o Types and amounts sold or distributed in 2013 , regardless of when the product was produced.

o An estimate of the amount expected to be produced in 20 1 4

. 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://compliance.supportportal.com/link/portal/23002/23009/ArticleFolder/1654/Pesticide

ProducersOMB Control No. 2070

- 0078 Expires on 3/31/2016

3  DO NOT REPORT :

o Production, distribution or sale of products NOT p roduced 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 48

, 49 and 50 are zero.

o Pesticides that are applied by your staff.

o Custom

- blended products

.

4. When to report:

 Annual Reports are due: On or before March 1, 20 1 4 , 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.

5. Completing the Report:

 Enter the company official’s or authorized agent’s Name and Title (Items 36 and 37 ).

 An original signature of a company official or authorized agent is required on the report in Item 38

.

 E nter the date in Item 39

.

 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 report for your record s

.

 EPA will not accept any copies, faxes or emails of establishment initial or annual reports

.

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

 Failure to file the initial or annual report is an unlawful act and may result in civil penalties up to $7,500 per violation or termination of the establishment’s registration

.

7. How to inactivate an establishment’s registration :

 Send a letter on company letterhead with this report stating the establishment is out of business or has ceased production of pesticides, active ingredients or devices requesting that

an establishment number be inactivated

.

 If EPA terminates your domestic establishment registration, it is illegal to sell or distribute any pesticide , active ingredient or device 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 the United States.



### 8. Additional Information is available at Pesticide Establishment

— Registration and Reporting Questions at: http://compliance.s upportportal.com/link/portal/23002/23009/ArticleFolder/1654/Pesticide

ProducersOMB Control No. 2070

- 0078 Expires on 3/31/2016

4 

### General Instructions

Establishment Information : ( Item s 1 through 1 8 )

 Item 1

— Establishment Name : E nter the producing establishment name.

 Item 2

— Establishment Number : E nter the producing establishment number.

 Item 3 to 8

— Establishment Site Address : E nter the SITE address

, not a post office box or
route number , where your establishment is located.

 Item 9 to 14

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

 Item 15

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

 Item 1 6

— eM ail : Enter your e m ail address.

 Item 17

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

 Item 1 8

— Did you produce or distribute in 2013 ? Check the appropriate box.

Note: If you checked the “No” box, do not fill in I tems 40 through 51

.

Company Information : ( Item s 1 9 through 35 )

 Item 1 9

— Company Name : E nter the company name

.

 Item 20 to 25

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

.

 Item 2 6 to 31

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

 Item 32

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

compan ies , please provide the country code.

 Item 33

— eM ail : Enter your e m ail address

.

 Item 34

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

 Item 35

— 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 Pag e 9

. NOTE: For items 7, 13, 24 and 30

— 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 y ou do not see the appropriate country code listed

. http://compliance.supportportal.com/link/portal/23002/23009/ArticleFolder/1654/Pesticide

Pro ducersOMB Control No. 2070

- 0078 Expires on 3/31/2016

5 Pesticide Production Information : ( Item s 40 through 51 )

 Item 40

— 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.

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 Registry numbers (if available); and the percentag e, by weight, of each ingredient (must total 100%). Multiple formulations may appear on the same page; clearly identify each by product name.

 Item 41

— 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 Use Permit number.

o Product Code 4

— For devices

, leave Item 41 blank.

o Product Code 5

— For stand

- alone SLN Registrations

, enter the SLN registration number

in Item 41 (e.g., SLN

- CA

- 890022). A “ stand

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

o Product Code 6

— For Unregistered Pesticides

, leave Item 41 blank. NOTE: Foreign Establishments

– You must report production for products exported to or
marketed in the United States or its territories

. 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 pounds to other countries and 1,000 pounds to the United States; you should report 1 0 ,000 pounds produced and 1,000 distributed into the United States.OMB Control No. 2070

- 0078 Expires on 3/31/2016

6  Item 42

— Product Name :

List the most common brand name. If marketed under alternate brand names (ABN)

, add

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

 Item 4 3

— 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 Insecticide 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 knowledge that a chemical or substance t hey 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 44

— P roduct 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

r egistration number with each distributor company number and brand name and attach it to the
report.OMB Control No. 2070

- 0078 Expires on 3/31/2016

7  Item 45

— 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 46

— 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 47

— Unit of Measurement :

o @ = Each ( registered pesticides that are sold in a unit such as petri dishes)

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)

 Item 48

—Amount Produced in 2013 :

o Do not include amounts that are custom blended

, placed directly into application equipment

, or applied to a crop, commodity or site by your staff.

o Round all quantities to the nearest whole number

.

 Item 49

—Amount Sold or Distributed in 2013

- 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

, placed directly into application equipment

, 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 50

—Amount Sold or Distributed in 2013 to Foreign Markets (Exported):

o Enter the quantity exported from the United States in 2013 , regardless of when the product was produced.

o Round all quantities to the nearest whole number

.

o Foreign establishments enter “0” in Item 50

.OMB Control No. 2070

- 0078 Expires on 3/31/2016

8  Item 51

—Amount (Estimated) to be Produced in 20 1 4 :

o Enter an estimate of the quantity to be produced in 20 1 4

.

o Round all quantities to the nearest whole number

.

Signature Certification : ( Item s 36 through 39 )

 Item s 36 and 37

— 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.

 I tem s 38 and 39

— Signature of Company Official or Authorized Agent : The company official and/or authorized agent listed in Item 36 must sign and date the report in order for it to
be complete

.

Confidentiality. Under FIFRA §7(d) [7 USC §136e], information reported in Item s 48

, 4 9

, 50 and
51 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 confidentialit y for this information.

If you wish to assert a claim of confidentiality 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 desig nated 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 required 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 comments 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.

Env ironmental 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

- 0078 Expires on 3/31/2016 

### Where to Submit Applications

DOMESTIC PRODUCERS: Submit applications to the following EPA Regional Office where your company headquarters is located.

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

- 6534 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)
11201 Renner Boulevard Lenexa, KS 66219 Telephone: 913

- 551

- 7371 IA, KS MO, NE

U.S. EPA Region 3 Kyla Townsend

- McIntyre Pesticides and Asbestos Programs Branch (3LC62) 1650 Arch Street Philadelphia, PA 19103

- 2029 Telephone: 215

- 814

- 2045 DC, DE MD, PA VA, WV U.S. EPA Region 8
Dan Webster FIFRA Division (8ENF

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

- 312

- 7076 CO, MT ND, SD UT, WY

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

- 562

- 8997 AL, FL GA, KY MS, NC SC, TN U.S. EPA Region 9 Scott McWhorter FIFRA Section (ENF 3

- 3) 75 Hawthorne Street San Francisco, CA 94105

- 3901 Telephone: 415

- 972

- 3584 AZ, CA GU, HI MP, NV

U.S. EPA Region 5 Pesticide Reports Contact Pesticides & Toxics Compliance Section ( LC

- 8J)
77 West Jackson Boulevard Chicago, IL 60604 Telephone: 312

- 886

- 7061 IL, IN MI, MN OH, WI U.S. EPA Region 10
Erin Williams Pesticides and Toxics Unit (OCE

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

- 1128 Telephone: 206

- 553

- 0505 AK, ID OR, WA

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

U.S. Postal Service Mail Address Courier Delivery Address

Michelle Stevenson Michelle Stevenson U.S. Environmental Protection Agency U.S. Environmental Protection Agency Pesticides, Waste & Toxics Branch (222 7 A) William J. Clinton Building

— South 1200 Pennsylvania Avenue, NW Ariel Rios Building

-- South Washington, DC 20460

- 0001 USA 1200 Pennsylvania Avenue, NW, Room 6102 Telephone: 202

- 564

- 4203 Washington, DC 20004 USA

7