OMB Control Number: 2060
- 0482 Expiration D ate: 6/30/15

EPA Form # 5900

- 140 , Revised 7 /1 4



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

### CLASS I CONTROLLED SUBSTANCE METHYL BROMIDE **EXPORT ER**  **QUA RTERLY**  **REPORT** 

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

## SECTION 1 EXPORTING COMPA **NY IDENTIFICA TION**  **1.1 Date of Submi**  **ssion 1.**  **2 Original Submittal**  **Re -**  **submittal 1.**  **3 Number of Transactions Reported**  **1. 4**  **Number of Pages Submitted 1.5 Quarter and Year t**  **o Which This Report A pplies** 

1 st 

### 2 nd 

### 3 rd 

### 4 th 

### Year **1.6 Ex porting Company**  Company Name Street Address Ci ty State Zip Code Ex porter EIN Number from Customs Form 7525: 

### 1.7 Company Contact Identification Reporting Company Contact Person E
- mail Addre ss Phone Number Fax Number 

### 1.8 **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 penal ties 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 Atmos pheric Programs Mail Code: 6205T 1200 Pennsylvania Ave nue, NW Wa shington, D.C. 20460 **For Private Courier:** U.S. EPA Stratospheric Protection Division Office of Atmospheric Programs Room 4355CC 1201 Constitution Avenue , NW Wa shington, 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 p ublic without further notice to the company (40 CFR 2.203). The public reporting and recordkeeping burden for this collection of inform ation 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 throu gh the use of au tomated 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 the comple t ed form to this address.OMB Control Number: 2060
- 0482 Expiration D ate: 6/30/15

EPA Form # 5900

- 140 , Revised 7 /1 4



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

### CLASS I CONTROLLED SUBSTANCE METHYL BROMIDE **EXPORTER QUA**  **RTERLY REPORT**  

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

## SECTION **2 TRA NSA**  **CTION RECORDS (Reproduce**  **A dditional**  **S heets as**  **N eeded)**  **2.1 Company Name 2.2 Transaction Summaries** 

**TRA NSA**  **CTION #** Recipient Company Name Street Address City Country Postal Code Company Contact Person Phone Number Fax Number Port of Export from the U. S. Date of Export (mm/dd/yy) Quantity of Methyl Bromide Exported (kg) Purpose of export is for: Transformation Destruction QPS Critical Use Emergency Use Lab Use


### TRA **NSA CTION #**  Recipient Company Name Street Address City Country Postal Code Company Contact Person Phone Number Fax Number Port of Export from the U.S. Date of Export (mm/dd/yy) Quantity o f Methyl Bromide Exported (kg) Purpose of export is for: Transformation Destruction QPS Critical Use Emergency Use Lab Use


### TRA **NSA CTION #**  Recipient Company Name Street Address City Country Postal Code Company Contact Person P hone Number Fax Number Port of Export from the U.S. Date of Export (mm/dd/yy) Quantity of Methyl Bromide Exported (kg) Purpose of export is for: Transformation Destruction QPS Critical Use Emergency Use Lab UseOMB Control Num ber: 2060
- 0482 Expiration Date: 6/30/15

EPA Form # 5900

- 140 , Revised 7 /1 4



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

### CLASS I CONTROLLED SUBSTANCE METHYL BROMIDE **EXPORTER QUA**  **RTERLY REPORT**  

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

## SECTION **3 COMPA**  **NY EXPORT TOTA LS**  **(Reproduce A**  **dditional S**  **heets as N**  **eeded) 3**  **.1 Company Name 3**  **.2 Transaction Summaries for Methyl Bromide** 
**Country Exported To Quantity of Methyl Bromide**  **Exported (kg) Commodity Code 2903.30.1520** 
Transformation (kg) Destruction (kg) Quarantine and Preshipment (QPS) (kg) Critical Use (kg) Emergency Use (kg) Laboratory Use (kg)

**Total s**