	

  U.S. Environmental Protection Agency	

                 stratospheric ozone protection program

	class i controlled substance

methyl bromide exporter quarterly report

      	      1.2    FORMCHECKBOX  Original Submittal   
FORMCHECKBOX   Re-submittal

1.3 Number of Transactions Reported	  FORMTEXT        	1.4 
Number of Pages Submitted	  FORMTEXT        

1.5  Quarter and Year to Which This Report Applies 	  FORMCHECKBOX   1st
  	  FORMCHECKBOX   2nd	  FORMCHECKBOX   3rd	  FORMCHECKBOX   4th 	 
FORMTEXT         Year

1.6 Exporting Company 

	Company Name    FORMTEXT        



Street Address    FORMTEXT        



City    FORMTEXT        	State   FORMTEXT        
Zip Code   FORMTEXT        

1.7 Company Contact Identification

Reporting Company Contact Person

  FORMTEXT        	Phone Number

  FORMTEXT        	Fax Number

      

Title    FORMTEXT        

	Signature     FORMTEXT        	Date   FORMTEXT 
      



SEND COMPLETED FORMS TO:	For U.S. Postal Service:

Tracking System Program Manager

Stratospheric Protection Division

U.S. EPA (6205J)

1200 Pennsylvania Avenue, NW

Washington, DC  20460	For Private Courier:

Tracking System Program Manager

Stratospheric Protection Division

U.S. EPA (6205J)

1310 L Street, NW;  10th Floor

Washington, DC  20005

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).

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.

           SEQ CHAPTER \h \r 1 	

        U.S. Environmental Protection Agency

                   stratospheric ozone protection program	class i
controlled substance

methyl bromide exporter quarterly report

(Sec 82.13)

SECTION 2    TRANSACTION RECORDS

                             (Reproduce additional sheets as needed)

2.1 Company Name	  FORMTEXT        			

2.2 Transaction Summaries	



TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        	Street Address   
FORMTEXT        



City   FORMTEXT        	Country   FORMTEXT          
	Postal Code   FORMTEXT        

Company Contact Person   FORMTEXT        	Phone Number  
FORMTEXT        	Fax Number   FORMTEXT        

% of Methyl Bromide that is used, recycled or reclaimed   FORMTEXT 
      

Quantity of Methyl Bromide Exported (kg)   FORMTEXT        
Source of Methyl Bromide   FORMTEXT        

Date of Export (mm/dd/yy)

  FORMTEXT        	Port of Export from the U.S.

  FORMTEXT        	Exporter EIN Number from Customs Form 7525

  FORMTEXT        

Purpose of export is for:	Transformation  

  FORMCHECKBOX  	Destruction 

  FORMCHECKBOX  	QPS 

  FORMCHECKBOX  	Critical Use

  FORMCHECKBOX  	Emergency Use

  FORMCHECKBOX  	Article 5 Allowances

  FORMCHECKBOX  	Lab Use

  FORMCHECKBOX  



TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        	Street Address   
FORMTEXT        

City   FORMTEXT        	Country   FORMTEXT        
Postal Code   FORMTEXT        

Company Contact Person   FORMTEXT        	Phone Number  
FORMTEXT        	Fax Number   FORMTEXT        

% of Methyl Bromide that is used, recycled or reclaimed   FORMTEXT 
      

Quantity of Methyl Bromide Exported (kg)   FORMTEXT        
Source of Methyl Bromide   FORMTEXT        

Date of Export (mm/dd/yy)

  FORMTEXT        	Port of Export from the U.S.

  FORMTEXT        	Exporter EIN Number from Customs Form 7525

  FORMTEXT        

Purpose of export is for:	Transformation  

  FORMCHECKBOX  	Destruction 

  FORMCHECKBOX  	QPS 

  FORMCHECKBOX  	Critical Use

  FORMCHECKBOX  	Emergency Use

  FORMCHECKBOX  	Article 5 Allowances

  FORMCHECKBOX  	Lab Use

  FORMCHECKBOX  



TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        	Street Address   
FORMTEXT        

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  FORMTEXT        	Port of Export from the U.S.

  FORMTEXT        	Exporter EIN Number from Customs Form 7525

  FORMTEXT        

Purpose of export is for:	Transformation

  FORMCHECKBOX  	Destruction

  FORMCHECKBOX  	QPS

  FORMCHECKBOX  	Critical Use

  FORMCHECKBOX  	Emergency Use

  FORMCHECKBOX  	Article 5 Allowances

  FORMCHECKBOX  	Lab Use

  FORMCHECKBOX  

	

     U.S. Environmental Protection Agency

             stratospheric ozone protection program



class i controlled substance 

methyl bromide exporter quarterly report

(Sec 82.13)

 SECTION 3    COMPANY EXPORT TOTALS 

                      (Reproduce Additional Sheets as Needed)



 3.1 Company Name	    FORMTEXT        

 3.2 Transaction Summaries for Methyl Bromide



	

Country Exported To	Quantity of Methyl Bromide Exported (kg)

Commodity Code 2903.30.1520

	Transformation (kg)	Destruction (kg)	Article 5 (kg)	Quarantine and
Preshipment (QPS) (kg)	Critical Use Exemption (CUE) (kg)	Emergency Use
Exemption (kg)	Laboratory Use Exemption (kg)

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Totals	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

         

	OMB Control Number: 2060-0482

	Expiration Date: 8/31/11

EPA Form # 5900-140, Revised 6/08

	OMB Control Number: 2060-0482

	Expiration Date: 8/31/11

EPA Form # 5900-140, Revised 6/08

