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 substances (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 protection or health 

authority; (2) quarantine pests are pests of potential importance to the areas endangered thereby and not yet present there, or present but 

not widely distributed and being officially controlled. This definition excludes treatments of commodities not entering or leaving the United 

States or any State (or political subdivision thereof). 

Preshipment Applications, with respect to Class I, Group VI controlled substances (methyl bromide), are those non-quarantine 

applications applied within 21 days prior to export to meet the official requirements of the importing country or existing official 

requirements of the exporting country. Official requirements are those which are performed by, or authorized by, a national plant, animal, 

environmental, health or stored product authority. 

1.5 Signature of Reporting Company Representative

I certify that the quantities of methyl bromide specified in Section 1.2 of this form are ordered/purchased and will be used exclusively for 

quarantine & preshipment applications as defined 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 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: 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 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.