OMB
#
2060­
0170
Expiration
Date:
8/
31/
05
U.
S.
Environmental
Protection
Agency
STRATOSPHERIC
OZONE
PROTECTION
PROGRAM
CLASS
I
CONTROLLED
SUBSTANCE
REPORT:

CERTIFICATION
OF
ORDER/
PURCHASE
OF
QPS
METHYL
BROMIDE
(
Sec
82.13(
y)(
1)­(
2))
AND
Sec
82.13(
z)(
2))

SECTION
1
PURCHASER
IDENTIFICATION
AND
METHYL
BROMIDE
USE
1.1
Date
of
Submission
1.2
Quantity
of
Methyl
Bromide
Ordered/
Purchased
(
kg)

1.3
Company
Information
Purchaser
Name
Street
Address
City
State
Zip
Code
1.4
Company
Contact
Identification
Reporting
Company
Contact
Person
Phone
Number
Fax
Number
Quarantine
Applications,
with
respect
to
class
I,
Group
VI
controlled
substances
(
methyl
bromide),
are
treatments
to
prevent
the
introduction,
establishment
and/
or
spread
of
quarantine
pests
(
including
diseases),
or
to
ensure
their
official
control,
where:
(
1)
Official
control
is
that
performed
by,
or
authorized
by,
a
national
(
including
state,
tribal
or
local)
plant,
animal
or
environmental
protection
or
health
authority;
(
2)
quarantine
pests
are
pests
of
potential
importance
to
the
areas
endangered
thereby
and
not
yet
present
there,
or
present
but
not
widely
distributed
and
being
officially
controlled.
This
definition
excludes
treatments
of
commodities
not
entering
or
leaving
the
United
States
or
any
State
(
or
political
subdivision
thereof).
Preshipment
Applications,
with
respect
to
class
I,
Group
VI
controlled
substances
(
methyl
bromide),
are
those
non­
quarantine
applications
applied
within
21
days
prior
to
export
to
meet
the
official
requirements
of
the
importing
country
or
existing
official
requirements
of
the
exporting
country.
Official
requirements
are
those
which
are
performed
by,
or
authorized
by,
a
national
plant,
animal,
environmental,
health
or
stored
product
authority.

1.5
Signature
of
Reporting
Company
Representative
Check
one
box
only.
I
certify
that
the
quantities
of
methyl
bromide
specified
in
Section
1.2
of
this
form
are
ordered/
purchased
and
will
be
used
exclusively
for
quarantine
&
preshipment
applications
as
defined
above,
and
not
sold/
transferred
to
another
person.
will
not
be
used
for
quarantine
&
preshipment
applications
as
defined
above.
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:
The
Company
from
Whom
the
Methyl
Bromide
is
being
Ordered/
Purchased
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)

Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
16
hours
per
response.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
The
OMB
control
numbers
for
EPA's
regulations
are
listed
in
40
CFR
Part
9
and
48
CFR
Chapter
15.
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,
OPPE
Regulatory
Information
Division,
U.
S.
Environmental
Protection
Agency
(
2137),
1200
Pennsylvania
Avenue,
NW,
Washington,
D.
C.
20460;
and
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Officer
for
EPA.
Include
the
EPA
ICR
number
and
OMB
control
number
in
any
correspondence.
DO
NOT
SEND
THIS
FORM
TO
THESE
ADDRESSES;
ONLY
SEND
COMMENTS.

ICR
NUMBER
1432.22­
C­
1MB,
Revised
5/
05
