OMB Control Number: 2060-0482 

Expiration Date: 10/31/11 

EPA Form # 5900-140, Revised 6/08

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE EXPORTER QUARTERLY REPORT

(Sec 82.13)

SECTION 1 EXPORTING COMPANY IDENTIFICATION

1.1 Date of Submission 1.2 Original Submittal Re-submittal

1.3 Number of Transactions 

Reported

 1.4 Number of Pages 

Submitted

 

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

 Year

1.6 Exporting Company 

Company Name 

Street Address 

City State Zip Code 

1.7 Company Contact Identification

Reporting Company Contact Person 

 

Phone Number 

 

Fax Number 

 

E-mail Address 

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 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 18 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. 

 
OMB Control Number: 2060-0482 

Expiration Date: 10/31/11 

EPA Form # 5900-140, Revised 6/08

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE EXPORTER QUARTERLY REPORT

(Sec 82.13)

SECTION 2 TRANSACTION RECORDS 

 (Reproduce additional sheets as needed)

2.1 Company Name 

2.2 Transaction Summaries

TRANSACTION # 

Recipient Company Name Street Address 

City Country Postal Code 

Company Contact Person Phone Number Fax Number 

% of Methyl Bromide that is used, recycled or reclaimed 

Quantity of Methyl Bromide Exported (kg) Source of Methyl Bromide 

Date of Export (mm/dd/yy) 

 

Port of Export from the U.S. 

 

Exporter EIN Number from Customs Form 7525 

 

Purpose of export 

is for:

Transformation Destruction QPS Critical Use Emergency Use Article 5 Allowances Lab Use 

TRANSACTION # 

Recipient Company Name Street Address 

City Country Postal Code 

Company Contact Person Phone Number Fax Number 

% of Methyl Bromide that is used, recycled or reclaimed 

Quantity of Methyl Bromide Exported (kg) Source of Methyl Bromide 

Date of Export (mm/dd/yy) 

 

Port of Export from the U.S. 

 

Exporter EIN Number from Customs Form 7525 

 

Purpose of export 

is for:

Transformation Destruction QPS Critical Use Emergency Use Article 5 Allowances Lab Use 

TRANSACTION # 

Recipient Company Name Street Address 

City Country Postal Code 

Company Contact Person Phone Number Fax Number 

% of Methyl Bromide that is used, recycled or reclaimed 

Quantity of Methyl Bromide Exported (kg) Source of Methyl Bromide 

Date of Export (mm/dd/yy) 

 

Port of Export from the U.S. 

 

Exporter EIN Number from Customs Form 7525 

 

Purpose of export 

is for:

Transformation Destruction QPS Critical Use Emergency Use Article 5 Allowances Lab Use 
OMB Control Number: 2060-0482 

Expiration Date: 10/31/11 

EPA Form # 5900-140, Revised 6/08

U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE 

METHYL BROMIDE EXPORTER QUARTERLY REPORT

(Sec 82.13)

 SECTION 3 COMPANY EXPORT TOTALS 

(Reproduce Additional Sheets as Needed)

 3.1 Company Name 3.2 Transaction Summaries for Methyl Bromide

Quantity of Methyl Bromide Exported (kg) 

Commodity Code 2903.30.1520

Country Exported To

Transformation (kg) Destruction (kg) Article 5 (kg) Quarantine and Preshipment (QPS) (kg) Critical Use Exemption (CUE) (kg) Emergency Use Exemption (kg) Laboratory Use Exemption (kg) 

Totals