OMB Control Number: 2060

- 0482 Expiration Date: 6/30/15

EPA Form # 5900

- 139 , Revised 6 /1 2



### U.S. Environmental Protection Agency **STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS I CONTROLLED SUBSTANCE METHYL BROMIDE **CERTIFICA**

**TION OF PUR CHA** 

**SE OF CRITICA**  **L USE METHYL BROMIDE**  

### (40 **CFR 82.**  **13 )**  

## SECTION 1 **PURCHA SER INDENTIFICA**  **TION 1.1 Date of Submission**  **1.2 Total Quantity of New Production Pre -**  **Plant Critical Use Methyl Bromide Purchased (kg) 1.3 Total Quantity of New Production Post Harvest Critical Use Methyl Bromide Purchased (kg)**  **1. 4**  **Company Informat**  **ion** Company Name Street Address City State Zip Code 

### 1. **5 Company Contact Identification**  Reporting Company Contac t Person E

- mail Address Phone Number Fax Number Approved critical use(s) are those uses of methyl bromide listed in Appendix L to Subpart A of 40 CFR Part 82 . See www.e pa.gov/ozone/ mbr/cueuses.html. 

### 1. **6 Signature of Reporting Company Representative**  I certify, under penalty of law, that the quantities of methyl bromide sp ecified in Section 1.2 and 1.3 of this form, are ordered/purchased and will be sold or used exclusi vely for an approved critical use (pre

- plant or post

- harvest) as identified, and not sold/ transferred to another person. I certify that I am an approved critical user and I will use this quantity of methyl bromide for an approved critical use. My action c onforms to the requirements associated with the critical use exemption published in 40 CFR part 82. I am aware that any agricultural commodity within a treatment chamber, facility or field I fumigate with critical use methyl bromide cannot subse quently or concurrently be fumigated with non

- critical use methyl bromide during the same control period, excepting a QPS treatment or treatment for a different use (e.g., a different crop or commodity). I will not use this quantity of methyl bromide for a treatment chamber, facility, or field that I previously fumigated with non

- critical use methyl bromide during the same control period, excepting a QPS treatment or treatments for a different use (e.g., a different crop or commodity), unless a local township limit no w prevents me from using methyl bromide alternatives or I have now become an approved critical user as a result of rulemaking. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all att ached 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 submitt ing false information, including the possibility of fine and imprisonment. Name Title Signature Date


## SEND COMPLETED FORMS TO: **The Company From Whom the Critical Use Methyl Bromide is Being Purchased**  The public reporting and recordkeeping burden for this colle ction 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 r espondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., N W, W ashington, D.C. 20460. Include the OMB control number in any correspondence. Do not send th e completed form to this address.