	

	U.S. Environmental Protection Agency

                    stratospheric ozone protection program

	class i controlled substance

methyl bromide

exporter quarterly report

      

Title    FORMTEXT        

Signature    FORMTEXT        	Date    FORMTEXT 
      

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

U.S. EPA

Stratospheric Protection Division

Office of Atmospheric Programs

Mail Code: 6205T

1200 Pennsylvania Avenue, NW

Washington, D.C. 20460	For Private Courier:

U.S. EPA

Stratospheric Protection Division

Office of Atmospheric Programs

Room 4355CC

1201 Constitution Avenue, NW 

Washington, D.C. 20004



A company may assert a claim of confidentiality for information
submitted in this form 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 1.3 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

(40 CFR 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        

Port of Export from the U.S.    FORMTEXT        	Date of
Export (mm/dd/yy)    FORMTEXT        

Quantity of Methyl Bromide Exported (kg)   FORMTEXT        

Purpose of export is for:	  FORMCHECKBOX   Transformation  

  FORMCHECKBOX   Destruction 	  FORMCHECKBOX   QPS 

  FORMCHECKBOX   Critical Use	  FORMCHECKBOX   Emergency Use

  FORMCHECKBOX   Lab Use



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        

Port of Export from the U.S.    FORMTEXT        	Date of
Export (mm/dd/yy)    FORMTEXT        

Quantity of Methyl Bromide Exported (kg)   FORMTEXT        

Purpose of export is for:	  FORMCHECKBOX   Transformation  

  FORMCHECKBOX   Destruction 	  FORMCHECKBOX   QPS 

  FORMCHECKBOX   Critical Use	  FORMCHECKBOX   Emergency Use

  FORMCHECKBOX   Lab Use



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 hone Number    FORMTEXT        	Fax Number    FORMTEXT 
      

Port of Export from the U.S.    FORMTEXT        	Date of
Export (mm/dd/yy)    FORMTEXT        

Quantity of Methyl Bromide Exported (kg)   FORMTEXT        

Purpose of export is for:	  FORMCHECKBOX   Transformation  

  FORMCHECKBOX   Destruction 	  FORMCHECKBOX   QPS 

  FORMCHECKBOX   Critical Use	  FORMCHECKBOX   Emergency Use

  FORMCHECKBOX   Lab Use



	

     	U.S. Environmental Protection Agency

                    stratospheric ozone protection program



class i controlled substance

methyl bromide

exporter quarterly report

(40 CFR 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)	Quarantine and Preshipment (QPS)
(kg)	Critical Use (kg)	Emergency Use (kg)	Laboratory Use (kg)

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Totals	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

         

	OMB Control Number: 2060-0482

	Expiration Date: 6/30/15

EPA Form # 5900-140, Revised 7/14

	OMB Control Number: 2060-0482

	Expiration Date: 6/30/15

EPA Form # 5900-140, Revised 7/14

