OMB Control Number: 2060

- 0482

Expiration Date: 10/31/ 14

EPA Form # 5900

- 139 , Revised 5/11



### U.S. Environmental Protection Agency

STRATO SPHERIC OZONE PROTEC TION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

METHYL BROMIDE

CERTIFICATION OF PUR CHASE OF CRITICAL

USE METHYL BROMIDE 

### (40 CFR 82. 13 )



## SECTION 1 PURCHASER INDENTIFICATION

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 Total Quantity of Critical Stock Methyl Bromide Purchased (for CSA Allocations) (kg)

1. 5 Company Information

Purchaser Name

Street Address

City State Zip Code



### 1. 6 Company Contact Identification

Reporting Company Contact Person Phone Number Fax Number

E

- mail Address

Critical u se methyl bromide means the methyl bromide produced or imported through expending a critical use allowance or inventory

produced or imported prior to the January 1, 2005 phaseout date that is sold only for approved critical uses through expendin g a critica l stock

allowance.

Approved critical use(s) are those uses of methyl bromide listed in Appendix L to Subpart A of 40 CFR Part 82 . See

http://www.epa.gov/ozone/ mbr/cueuses.html.



### 1. 7 Signature of Reporting Company Representative

I certify, under penalty of law, that the quantities of methyl bromide specified in Section 1.2, 1.3, and 1.4 of this form, are ordered/purchased

and will be sold or used exclusively 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

conforms to the requirements associated with the critical use exemption published in 40 CFR part 82. I a m aware that any agricultural

commodity within a treatment chamber, facility or field I fumigate with critical use methyl bromide cannot subsequently or co ncurrently be

fumigated with non

- critical use methyl bromide during the same control period, exceptin g a QPS treatment or treatment for a different use (e.g.,

a different crop or commodity). I will not use this quantity 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 now prevents me from using methyl bromide alternatives or I have now become an approved critica l 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 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

Signatur e 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 collection of information is estimated to avera ge 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., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the comple ted form to this address.