U.
S.
Environmental
Protection
Agency
Office
of
Transportation
and
Air
Quality
Fuel
Additive
Manufacturer
Notification
Form
Approval
OMB
No.
2060­
0150
Approval
Expires
01/
31/
2004
Leave
Blank
1.
Additive
(
Comercial
Name):

2.
Company
Name:
2a.
Company
ID:

3.
Address:

4.
Method
of
Use
(
Check
as
Appropriate):

g
f
e
d
c
Bulk
Treatment
­
Blended
into
fuel
prior
to
being
dispensed
into
a
vehicle.
g
f
e
d
c
Aftermarket
­
Sold
in
consumer­
sized
containers
for
addition
to
a
vehicle's
fuel
system.

5.
Recommended
Usage
and
Range
of
Concentration
(
Complete
as
appropriate.
If
this
is
an
aerosol,
only
indicate
the
recommended
frequency
of
use)

Bulk
Treatment
For
Use
In
Range
of
Additive
Concentration
(
)
Units
Aftermarket
For
Use
In
Range
of
Additive
Concentration
(
)
Units
Highest
Lowest
Average
Highest
Lowest
Average
Unleaded
Motor
Vehicle
Gasoline
Unleaded
Motor
Vehicle
Gasoline
Motor
Vehicle
Diesel
Fuel
Motor
Vehicle
Diesel
Fuel
If
this
is
an
aerosol,
recommended
frequency
of
use:

6.
Recommended
Purpose­
In­
Use
of
the
fuel
additive
named
in
Item
1
(
Check
Appropriate
Item(
s)).

Gas
Diesel
Purpose­
In­
Use
g
f
e
d
c
g
f
e
d
c
(
a)
Anti­
icing
agent/
moisture
absorbent
g
f
e
d
c
g
f
e
d
c
(
b)
Antiknock
g
f
e
d
c
g
f
e
d
c
(
c)
Antioxidant
g
f
e
d
c
g
f
e
d
c
(
d)
Antistall
agent
g
f
e
d
c
g
f
e
d
c
(
e)
Antistatic
agent
g
f
e
d
c
g
f
e
d
c
(
f)
Cetane
improver
g
f
e
d
c
g
f
e
d
c
(
g)
Combustion
improver/
modifier
g
f
e
d
c
g
f
e
d
c
(
h)
Corrosion
inhibitor
g
f
e
d
c
g
f
e
d
c
(
i)
Deposit
modifier/
control
g
f
e
d
c
g
f
e
d
c
(
j)
Detergent
g
f
e
d
c
g
f
e
d
c
(
k)
Dye
g
f
e
d
c
g
f
e
d
c
(
l)
Gum
solvent
g
f
e
d
c
g
f
e
d
c
(
m)
Masking
or
odorizing
agent
g
f
e
d
c
g
f
e
d
c
(
n)
Metal
deactivator
g
f
e
d
c
g
f
e
d
c
(
o)
Pour
point
depressant
g
f
e
d
c
g
f
e
d
c
(
p)
Sediment
inhibitor
g
f
e
d
c
g
f
e
d
c
(
q)
Stabilizer
or
dispersant
g
f
e
d
c
g
f
e
d
c
(
r)
Upper
cylinder
lubricant
g
f
e
d
c
g
f
e
d
c
(
s)
Octane
enhancer
g
f
e
d
c
g
f
e
d
c
(
t)
Flow
improver
g
f
e
d
c
g
f
e
d
c
(
u)
Volume
extender
g
f
e
d
c
g
f
e
d
c
(
v)
Carburetor
and
choke
cleaner
g
f
e
d
c
g
f
e
d
c
(
v)
Algaecide/
bactericide/
fungicide
g
f
e
d
c
g
f
e
d
c
(
x)
Valve
lubricant
g
f
e
d
c
g
f
e
d
c
(
y)
Demulsifier/
dehazer
Gas
Diesel
Purpose­
In­
Use
g
f
e
d
c
g
f
e
d
c
(
ac)
Additive
component
g
f
e
d
c
g
f
e
d
c
(
af)
Anti­
flamant
g
f
e
d
c
g
f
e
d
c
(
an)
Acid
neutralizer
g
f
e
d
c
g
f
e
d
c
(
bc)
Blended
component/
blend
stock
g
f
e
d
c
g
f
e
d
c
(
bd)
Biodiesel
g
f
e
d
c
g
f
e
d
c
(
ca)
Carrier
g
f
e
d
c
g
f
e
d
c
(
cc)
Combustion
chamber
cleaner
g
f
e
d
c
g
f
e
d
c
(
cp)
Cloud
point
depressant
g
f
e
d
c
g
f
e
d
c
(
dc)
Detergent
compound
g
f
e
d
c
g
f
e
d
c
(
df)
Defoamer
g
f
e
d
c
g
f
e
d
c
(
di)
Dilutent
g
f
e
d
c
g
f
e
d
c
(
ec)
Emission
control
g
f
e
d
c
g
f
e
d
c
(
es)
Exhaust
system
cleaner
g
f
e
d
c
g
f
e
d
c
(
fr)
Certified
detergent
g
f
e
d
c
g
f
e
d
c
(
ia)
Identifying
agent
g
f
e
d
c
g
f
e
d
c
(
ic)
Fuel
injector
cleaner
g
f
e
d
c
g
f
e
d
c
(
iv)
Intake
valve
cleaner
g
f
e
d
c
g
f
e
d
c
(
la)
Lubricity
agent
g
f
e
d
c
g
f
e
d
c
(
mr)
Marker
g
f
e
d
c
g
f
e
d
c
(
ox)
Oxygenate
g
f
e
d
c
g
f
e
d
c
(
pc)
Process
chemical
g
f
e
d
c
g
f
e
d
c
(
ri)
Rust
inhibitor
g
f
e
d
c
g
f
e
d
c
(
sf)
Starting
Fluid
g
f
e
d
c
g
f
e
d
c
(
sw)
Sweetener
g
f
e
d
c
g
f
e
d
c
(
tr)
Tracer
Page
1
of
6
EPA
Form
3520­
13
(
06­
2003)
­
Fuel
Additive
Manufacturer
Notification
7.
Chemical
Composition:

(
c)
Information
on
the
chemical
process
of
manufacturer
is
attached.
Yes
No
(
a)
Names
of
Additive
Compounds
or
Components
Component
Percent
Methods
of
Analysis
Chemical
Abstract
Service
No.

(
b)
Elemental
Breakdown
Elemental
Percent
Methods
of
Analysis
g
f
e
d
c
g
f
e
d
c
8.
Chemical
Structure
­
Is
the
chemical
structure
of
all
components
completely
defined
by
the
names
given
under
Item
7(
a)?

g
f
e
d
c
Yes
g
f
e
d
c
No
If
"
No,"
attach
seperate
sheet(
s)
providing
the
complete
structures
of
such
components,
so
far
as
they
are
known.
9.
Impurities
­
If
greater
than
0.1%
by
weight,
to
the
extent
known:

Names
of
Impurities
Percent
by
Weight
Method
of
Analysis
Highest
Lowest
Average
Page
2
of
6
EPA
Form
3520­
13
(
06­
2003)
­
Fuel
Additive
Manufacturer
Notification
10.
Do
you
know
of
any
analytical
techniques
that
can
be
used
to
detect
the
presence
of
this
fuel
additive
and/
or
measure
its
concentration
in
gasoline
and/
or
diesel
fuel?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
attach
separate
sheet(
s)
providing
the
information.

11.
Do
you
have
any
information
developed
by
or
for
you
concerning
the
mechanisms
of
action
of
this
fuel
additive;
reactions
between
this
fuel
additive
and
gasoline
and/
or
diesel
fuel;
the
identification
and
measurement
of
the
emission
products
of
this
fuel
additive
when
used
in
gasoline
and/
or
diesel
fuel;
the
effects
of
this
fuel
additive
on
all
emissions;
the
toxicity
and
any
other
public
health
or
welfare
effects
of
the
emission
products
of
this
fuel
additive;
and/
or
the
effects
of
the
emission
products
on
the
performance
of
emission
control
devices
or
systems?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
attach
separate
sheet(
s)
providing
summaries
and
a
description
of
the
test
procedures
used
in
obtaining
the
information.
12.
Is
this
additive
a
relabel
of
an
additive
currently
registered
under
40
CFR
section
79?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
enter
the
name
of
the
additive
and
its
manufacturer.

Name
of
registered
additive:

Manufacturer:

13.
Annual
Production
­
What
is
the
estimated
annual
volume,
in
gallons,
of
this
additive
during
the
third
year
of
production?

Bulk:
Aftermarket:

14.
Market
Distribution
­
To
the
nearest
percent
(
no
decimals),
estimated
for
the
third
year
of
production,
enter
the
percent
of
sales
by
Petroleum
Administration
for
Defense
District
(
PADD)
for
the
bulk
additive
volume
and
the
percent
of
sales
for
each
state
for
the
aftermarket
additive
volume.

Bulk:
PADD1
PADD2
PADD3
PADD4
PADD5
Aftermarket:

CT
IL
AL
CO
AK
DE
IN
AR
ID
AZ
DC
IA
LA
MT
CA
FL
KS
MS
UT
HI
GA
KY
NM
WY
NV
ME
MI
TX
OR
MD
MN
WA
MA
MO
NY
NE
NH
ND
NJ
OH
NC
OK
PA
SD
RI
TN
SC
WI
VT
VA
WV
Page
3
of
6
EPA
Form
3520­
13
(
06­
2003)
­
Fuel
Additive
Manufacturer
Notification
If
you
answered
"
yes"
to
item
12,
skip
to
item
19.

15.
Is
this
fuel
additive
derived
only
from
conventional
petroleum,
heavy
oil
deposits,
coal,
tar
sands,
and/
or
oil
sands?

g
f
e
d
c
Yes
g
f
e
d
c
No
16.
Small
Business
Provisions
­
40
CFR
79.58(
d).

A
manufacturer
of
a
baseline
or
nonbaseline
additive
whose
average
of
the
previous
three
years
annual
sales
revenue
is
less
than
$
50
million
is
exempt
from
the
Tier
1
and
Tier
2
health­
effects
testing
requirements.
A
manufacturer
of
an
atypical
additive
whose
average
of
the
previous
three
years
annual
sales
revenue
is
less
than
$
10
million
is
exempt
from
the
Tier
2
requirements.
If
you
believe
that
you
qualify
for
an
exemption,
enter
below
your
sales
revenue
for
each
of
the
previous
three
years
and
the
average.

(
Note:
In
cases
where
subsidiary,
divisional,
or
other
complex
business
arrangements
exist,
the
business
entity
to
which
this
sales
level
pertains
is
the
parent
company
with
ultimate
ownership.
The
"
ultimate"
parent
is
defined
as
the
uppermost
headquarters
or
topmost
company
encompassing
all
related
parents,
subsidiaries,
divisions,
branches,
or
other
operating
units.
This
definition
follows
that
used
by
the
Small
Business
Administration.
It
also
helps
to
ensure
that
a
company
will
not
subdivide
merely
to
become
eligible
for
an
exemption.)

Annual
sales
revenue
3
years
ago:
$

Annual
sales
revenue
2
years
ago:
$

Annual
sales
revenue
1
year
ago:
$

Average
of
above:
$

Is
the
above
average
for
the
company
named
in
Item
2?

g
f
e
d
c
Yes
g
f
e
d
c
No
If
"
No,"
complete
the
following:

Name
of
the
parent
company
with
ultimate
ownership:

Address:

Contact
Name:
Phone:

Title:
Email:

17.
Aerosol
­
Is
this
an
aerosol
additive?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
do
you
claim
applicability
of
the
special
provisions
for
aerosol
additives
at
40
CFR
79.58(
e)?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
attach
the
information
required
for
an
aerosol
additive
and
skip
to
item
19.
Page
4
of
6
EPA
Form
3520­
13
(
06­
2003)
­
Fuel
Additive
Manufacturer
Notification
This
additive
is
covered
by
the
following
testing
group:

OR
I
have
attached
the
appropriate
information.
18.
Grouping
Information
­
Pursuant
to
40
CFR
section
79.56.
If
you
do
not
qualify
for
an
aerosol
or
Tier
1
and
Tier
2
small
business
exemption,
you
must
be
a
member
of
a
testing
group
appropriate
for
your
fuel
additive
or
supply
the
appropriate
health­
effects
test
information.

Group
description:

Organizing
entity:

Contact
person:

Telephone:

Address:

g
f
e
d
c
Yes
g
f
e
d
c
No
If
"
No,"
attach
an
explanation.

19.
Confidential
Business
Information
­
You
may
assert
a
business
confidentiality
claim
for
certain
items.
If
no
claim
is
made,
the
information
may
be
made
available
to
the
public
without
further
notice.
All
questions
of
confidentiality
will
be
handled
pursuant
to
40
CFR
2.

Do
you
wish
to
assert
a
claim
of
confidentiality
for
any
item?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
indicate
"
Yes"
or
"
No"
for
each
item
below:

Item
5:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
10:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
14:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
7:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
11:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
15:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
8:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
12:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
16:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
9:
g
f
e
d
c
Yes
g
f
e
d
c
No
Item
13:
g
f
e
d
c
Yes
g
f
e
d
c
No
20.
Attachments
­
Are
attachments
included
with
this
notification?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
list
below:
Page
5
of
6
EPA
Form
3520­
13
(
06­
2003)
­
Fuel
Additive
Manufacturer
Notification
21.
Certification
To
the
best
of
my
knowledge,
the
above
is
complete
and
correct.

I
am
authorized
by
the
manufacturer
to
submit
this
notification.

As
per
40
CFR
79.21(
f),
the
U.
S.
Environmental
Protection
Agency
would
be
notified
in
writing
if
certain
information
in
this
notification
were
to
change.

This
fuel
additive
manufacturer
will
not
represent,
directly
or
indirectly,
in
any
notice,
circular,
letter,
or
other
written
communication,
or
any
written,
oral,
or
pictorial
notice
or
other
announcement
is
any
publication
or
by
radio
or
television,
that
registration
of
this
fuel
additive
constitutes
endorsement,
certification,
or
approval
by
any
agency
of
the
United
States.

Signature:

Date:

Name
of
Signer
(
print):
Title:

Telephone:
Fax:

E­
mail:

Comments:

Mail
the
completed
form
to:

U.
S.
Environmental
Protection
Agency
Attn:
Fuel
Additive
Registration/
Suite
L
­
103
Mail
Code
­
6406J
1200
Pennsylvania
Avenue,
NW
Washington,
DC
20460­
0001
Telephone
(
202)
564
­
9754
Fax
(
202)
565­
2153
email:
caldwell.
jim@
epa.
gov,
fernandes.
joseph@
epa.
gov
This
office
is
operated
by
a
contractor
for
the
EPA.
or,
via
courier:

U.
S.
Environmental
Protection
Agency
Attn:
Fuel
Additive
Registration/
Suite
L
­
103
Mail
Code
­
6406J
501
Third
Street,
NW
Washington,
DC
20001
Page
6
of
6
EPA
Form
3520­
13
(
06­
2003)
­
Fuel
Additive
Manufacturer
Notification
