**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 PRO GRAM 

### 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 **1 st**  

### 2 **nd** 

### 3 **rd** 

### 4 **th** 

### 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 personal ly examined and am familiar with the information su bmitted in this and all attached

documents, and that based on my inquiry of those in dividuals immediately responsible for obtaining the information, I believe that the

submitted information is true, accurate, and comple te. I am aware that there are significant penaltie s 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; 10 th**  **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 i nformation** 

**submitted by clearly marking that information as co nfidential. Such information shall be treated in a**  **ccordance with EPA’s procedures for information cla imed as** 

**confidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the sub**  **part. If no claim of confidentiality accompanies t he report** 

**when it is received by EPA, it may be made public w ithout further notice to the company (40 CFR 2.203)** 

**.**

**The public reporting and recordkeeping burden for t his collection of information is estimated to avera**  **ge 18 hours per response. Send comments on the**

**Agency's need for this information, the accuracy of the provided burden estimates, and any suggested m**  **ethods 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. Inc lude 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 P ROGRAM 

### 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 recla imed** 

**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 recla imed** 

**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 recla imed** 

**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 Name3.2 Transaction Summaries for Methyl BromideQuantity of Methyl Bromide Exported (kg)Commodity Code 2903.30.1520Country 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