	  SEQ CHAPTER \h \r 1  

  U.S. Environmental Protection Agency

stratospheric ozone protection program	class i controlled substance

certification of order/purchase

of critical use methyl bromide 

      	    

1.2  Total   SEQ CHAPTER \h \r 1 Quantity of New Production Pre-Plant
Critical Use Methyl Bromide Ordered/ Purchased (kg)	  FORMTEXT 
      

1.3  Total   SEQ CHAPTER \h \r 1 Quantity of New Production Post-Harvest
Critical Use Methyl Bromide Ordered/Purchased (kg)	  FORMTEXT 
      

1.4  Total   SEQ CHAPTER \h \r 1 Quantity of Critical Stock Methyl
Bromide Ordered/ Purchased (for CSA Allocations) (kg)	  FORMTEXT 
      

1.5   Company Information

Purchaser Name    FORMTEXT        

Street Address   FORMTEXT        

City   FORMTEXT        	State   FORMTEXT        	Zip
Code   FORMTEXT        

1.6   Company Contact Identification

Reporting Company Contact Person

  FORMTEXT        	Phone Number

  FORMTEXT        	Fax Number

  FORMTEXT        

E-mail Address   FORMTEXT        

Critical use methyl bromide means the class I, Group VI controlled
substance produced or imported through expending a critical use
allowance or that portion of inventory produced or imported prior to the
January 1, 2005, phaseout date that is sold only for approved critical
uses through expending a critical stock allowance.

Approved critical use(s) are those uses of methyl bromide listed in
Column A of Appendix L to Subpart A of 40 CFR Part 82 as further
clarified in Columns B and C of that appendix.

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 am aware that
any agricultural commodity within a treatment chamber, facility or field
I fumigate with critical use methyl bromide cannot subsequently or
concurrently be fumigated with non-critical use methyl bromide during
the same control period, excepting 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 critical 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    FORMTEXT        

Title    FORMTEXT        

Signature     FORMTEXT        

	

Date   FORMTEXT        

SEND COMPLETED FORMS TO:	The Company From Whom the Critical Use Methyl
Bromide is Being Ordered/Purchased



The public reporting and recordkeeping burden for this collection of
information is estimated to average 18 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
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.  Include the OMB control number in any
correspondence.  Do not send the completed form to this address.

        

  U.S. Environmental Protection Agency

stratospheric ozone protection program	class i controlled substance

certification of order/purchase

of critical use methyl bromide 

      

2.2 New Production Critical Use Methyl Bromide to be used for the
following approved critical uses (active ingredient only)

Pre-Plant 	Post-Harvest

Cucurbits:    FORMTEXT         (kg) 	Food Processing (please
do not include NPMA amounts):  

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Eggplant:    FORMTEXT         (kg)	Commodity Storage :   
FORMTEXT         (kg)

Forest Seedlings:     FORMTEXT         (kg)	Dry Cured Pork
Products :    FORMTEXT         (kg)

Orchard Nursery Seedlings:    FORMTEXT         (kg)	National
Pest Management Association:    FORMTEXT         (kg)

Orchard Replant:     FORMTEXT         (kg)

	Ornamentals:    FORMTEXT         (kg)

	Peppers:    FORMTEXT         (kg)

	Strawberry Nurseries:     FORMTEXT         (kg)

	Strawberry Fruit:    FORMTEXT         (kg)

	Sweet Potato Slips:    FORMTEXT         (kg)

	Tomatoes:    FORMTEXT         (kg)

	2.3 Critical Stock Allowance Methyl Bromide (supplied from pre-2005
phaseout stocks) to be used for (active ingredient only):

Pre-Plant 	Post-Harvest

Cucurbits:    FORMTEXT         (kg) 	Food Processing (please
do not include NPMA amounts):

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)	Dry Cured Pork Products :    FORMTEXT         (kg)

Orchard Nursery Seedlings:    FORMTEXT         (kg)	National
Pest Management Association:    FORMTEXT         (kg)

Orchard Replant:    FORMTEXT         (kg)

	Ornamentals:    FORMTEXT         (kg)

	Peppers:    FORMTEXT         (kg)

	Strawberry Nurseries:     FORMTEXT        (kg)

	Strawberry Fruit:    FORMTEXT          (kg)

	Sweet Potato Slips:    FORMTEXT         (kg)

	Tomatoes:    FORMTEXT         (kg)

	

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2060-0482

	Expiration Date: 8/31/11

EPA Form # 5900-139, Revised 6/08

