OMB Control Number: 2060-0170 Expiration Date: 4/30/12

EPA Form # 5900-154, Revised 04/09 

### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

CERTIFICATION OF ORDER 

### / PURCHASE

OF QPS METHYL BROMIDE 

### (Sec 82.13)



## SECTION 1 PURCHASER IDENTIFICATION AND METHYL BROMIDE USE

1.1 Date of

Submission 1.2 Quantity of Methyl Bromide Ordered/ Purchased (kg)

1.3 Company Information

Purchaser Name

Street Address

City State Zip Code



### 1.4 Company Contact Identification
Reporting Company Contact Person Phone Number Fax Number

E-mail Address

Quarantine Applications , with respect to Class I, Group VI controlled substanc es (methyl bromide), are treatments to prevent the introduction, establishment and/or spread of quarantine pests (including diseases), or to ensure their official control, where: (1) Official control is that performed by, or authorized by, a national (including state, tribal or local) plant, animal or environmental pr otection or health authority; (2) quarantine pests are pests of potential importance to the areas endangered thereby and not ye t present there, or present but not widely distributed and being officially controlled. This def inition excludes treatments of commodities not entering or leav ing the United States or any State (or polit ical subdivision thereof).

Preshipment Applications , with respect to Class I, Group VI controlled subs tances (methyl bromide), are those non-quarantine applications applied within 21 days prior to export to meet the official requirements of the impor ting country or existing offi cial requirements of the exporting country. Offici al requirements are those which are perfo rmed by, or authorized by, a national pla nt, animal, environmental, health or stored product authority.



### 1.5 Signature of Reporting Company Representative

I certify that the quantities of methyl br omide specified in Section 1.2 of this fo rm are ordered/purchased and will be used ex clusively for quarantine & preshipment applications as de fined above, and not sold/ transferred to another person. 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 m y inquiry of those individuals immediately responsible for obtaini ng 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 f ine and imprisonment.

Name

__________________________________________________________________

Title

____________________________________________________________________
Signature

_______________________________________________________________ Date

_______________________________________



## SEND COMPLETED FORMS TO: The Company from Whom the Methyl Bromide is Being Ordered/Purchased

The public reporting and recordkeeping burden for this collection of information is estimated to average 2.4 hours per response . Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any sugges ted methods for minimizing res pondent burden, including through the use of automated collection techniques to the Director , Collection Strategies Division, U.S. Environmental Protecti on 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.