OMB Control Number: 2060-0170 

Expiration Date: 4/30/12 

EPA Form # 5900-155, Revised 04/09

 U.S. Environmental Protection Agency 

STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

DISTRIBUTOR OF QPS 

METHYL BROMIDE QUARTERLY REPORT 

(Sec 82.13)

SECTION 1 DISTRIBUTOR IDENTIFICATION

 1.2 Total Quantity of Methyl Bromide 

Delivered for Use in Certified QPS 

Applications (kg)

 

1.3 Original Submittal 

 Re-submittal

1.1 Date of 

Submission

1.4 Quarter and Year to Which This Report Applies 1st 2nd 3rd 4th Year 

1.5 Distributor Information

Company Name 

Street Address 

City State Zip Code 

1.6 Distributor Contact Identification

Reporting Distributor Contact Person 

 

Phone Number 

 

Fax Number 

 

E-mail Address 

1.7 Supplier Identification 

Supplier Name 

1.8 Signature of Reporting Distributor Representative

I certify that the total quantity of methyl bromide listed in this form was exclusively sold for use in quarantine & preshipment applications, 

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: For U.S. Postal Service: 

Tracking System Program Manager 

Stratospheric Protection Division 

U.S. EPA (6205J) 

1200 Pennsylvania Avenue, NW 

Washington, DC 20460 

For Private Courier: 

Tracking System Program Manager 

Stratospheric Protection Division 

U.S. EPA – (6205J) 

1310 L Street, NW; 10th Floor 

Washington, DC 20005

Information in reports submitted in compliance with the final rule may be claimed as confidential. A company may assert a claim of confidentiality for information 

submitted 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 public without further notice to the company (40 CFR 2.203). 

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.