U.
S.
Environmental
Protection
Agency
Office
of
Transportation
and
Air
Quality
Fuel
Manufacturer
Notification
for
Motor
Vehicle
Fuel
Form
Approval
OMB
No.
2060­
0150
Approval
Expires
01/
31/
2004
Leave
Blank
1.
Brand
name(
s)
of
the
motor
vehicle
fuel
covered
by
this
notification
(
list):

2.
Company
Name:
3.
Company
ID:

4.
Address:

5.
Type
of
Fuel
(
Check
Only
One)

g
f
e
d
c
(
a)
Unleaded
Premium
Gasoline
g
f
e
d
c
(
b)
Unleaded
Regular
Gasoline
g
f
e
d
c
(
c)
Unleaded
Midgrade
Gasoline
g
f
e
d
c
(
d)
Grade
1­
Diesel
g
f
e
d
c
(
e)
Grade
2­
Diesel
g
f
e
d
c
(
f)
Other
(
Specify):

6.
Fuel
Properties,
to
the
extent
known:
Percent
by
weight
Methods
of
Analysis
(
a)
through
(
f)
only
Highest
Lowest
Average
(
a)
Aromatics
(
b)
Olefins
(
c)
Saturates
(
d)
Polynuclear
Organic
Material
(
e)
Sulfur
(
f)
Trace
Elements
Gasoline:
(
g)
Reid
Vapor
Pressure
(
kPa
or
psi)

(
h)
Distillation:
10%
Point
(
°
C)

(
i)
Distillation:
End
Point
(
°
C)

(
j)
Research
Octane
Number
(
k)
Motor
Octane
Number
Diesel
Fuel:
(
I)
Distillation:
90%
Point
(
°
C)

(
m)
Distillation:
End
Point
(
°
C)

(
n)
Cetane
Number
or
Index
Page
1
of
5
EPA
Form
3520­
12
(
06­
2003)
­
Fuel
Manufacturer
Notification
for
Motor
Vehicle
Fuel
Page
2
of
5
EPA
Form
3520­
12
(
06­
2003)
­
Fuel
Manufacturer
Notification
for
Motor
Vehicle
Fuel
8.
Do
you
know
of
any
analytical
technique
that
can
be
used
to
detect
the
presence
of
any
of
the
reported
additives
in
this
fuel
and/
or
measure
their
concentration
therein?

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

9.
Do
you
have
any
information
developed
by
or
for
you
concerning
the
mechanisms
of
action
of
any
of
the
additives
reported;
reactions
between
the
additives
and
the
motor
vehicle
fuel;
the
identification
and/
or
measurement
of
the
emission
products
of
the
additives
when
used
in
the
motor
vehicle
fuel;
the
effects
of
the
additives
on
all
emissions;
the
toxicity
and
any
other
public
health
or
welfare
effects
of
the
emission
products
of
the
additives;
and/
or
the
effects
of
the
emission
products
of
the
gasoline
additives
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.
10.
To
the
nearest
percent,
estimated
for
the
third
year
of
production,
enter
the
percent
of
sales
by
Petroleum
Administration
for
Defense
District
(
PADD)
for
the
motor
vehicle
fuel.
See
instructions
for
the
states
in
each
PADD.

PADD1
PADD2
PADD3
PADD4
PADD5
11.
Is
this
fuel
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
12.
Small
Business
Provisions
­
40
CFR
79.58(
d).
(
See
instructions)

A
manufacturer
of
a
baseline
or
nonbaseline
fuel
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
fuel
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:
Page
3
of
5
EPA
Form
3520­
12
(
06­
2003)
­
Fuel
Manufacturer
Notification
for
Motor
Vehicle
Fuel
13.
Grouping
Information
­
If
you
do
not
qualify
for
a
small
business
provision,
you
must
be
a
member
of
a
testing
group
appropriate
for
your
fuel
or
supply
the
appropriate
health­
effects
test
information.

This
fuel
is
covered
by
the
following
testing
group:

Group
description:

Organizing
entity:

Contact
person:

Telephone:
Fax:

Email:

Address:
OR
I
have
attached
the
appropriate
information.

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

14.
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
of
items
6
through
12?

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

Item
6:
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
8:
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
10:
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
12:
g
f
e
d
c
Yes
g
f
e
d
c
No
15.
Attached
Information
­
Are
attachments
included
with
this
notification?

g
f
e
d
c
No
g
f
e
d
c
Yes
If
"
Yes,"
list
below:
Page
4
of
5
EPA
Form
3520­
12
(
06­
2003)
­
Fuel
Manufacturer
Notification
for
Motor
Vehicle
Fuel
16.
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
79.11(
g),
the
U.
S.
Environmental
Protection
Agency
would
be
notified
in
writing
if
certain
information
in
this
notification
were
to
change.

This
fuel
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
in
any
publication
or
by
radio
or
television,
that
registration
of
this
fuel
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
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
Registration/
Suite
L
­
103
Mail
Code
­
6406J
501
Third
Street,
NW
Washington,
DC
20001
Page
5
of
5
EPA
Form
3520­
12
(
06­
2003)
­
Fuel
Manufacturer
Notification
for
Motor
Vehicle
Fuel
