	U.S. Environmental Protection Agency

                    stratospheric ozone protection program	class i controlled substance

methyl bromide

certification of purchase of critical

	1.2  Total Quantity of New Production Pre-Plant Critical Use Methyl Bromide Purchased (kg)	  FORMTEXT

1.3  Total Quantity of New Production Post Harvest Critical Use Methyl Bromide Purchased (kg)	  FORMTEXT

1.4 Company Information

Company Name    FORMTEXT

Street Address    FORMTEXT

City    FORMTEXT        	State    FORMTEXT             	Zip Code    FORMTEXT

1.5 Company Contact Identification

Reporting Company Contact Person    FORMTEXT

E-mail Address    FORMTEXT

Phone Number    FORMTEXT        	Fax Number    FORMTEXT

Approved critical use(s) are those uses of methyl bromide listed in Appendix L to Subpart A of 40 CFR Part 82.  See www.epa.gov/ozone/mbr/cueuses.html.

1.6 Signature of Reporting Company Representative

I certify, under penalty of law, that the quantities of methyl bromide specified in Section 1.2 and 1.3 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 of methyl bromide for a treatment 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.

Title    FORMTEXT

Signature     FORMTEXT        	Date      FORMTEXT

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

h

h

摧ᮽÅ

 h

 h

 h

h

 h

 h

h

h

h

愀Ĥ摧ᮽÅ

愀Ĥ

愀Ĥ摧ᮽÅ

ÿX

®

°

Ä

Æ

È

Ò

Ô

Ö

Ø

Ü

Þ

î

 h

愀Ĥ摧ᮽÅ

̀Ö

Ø

J

†

.

0

2

<

>

H

J

^

`

t

v

x

‚

„

ˆ

j%

†

ˆ

Î

Ð

瑹ᮽÅ咊

 h

 h

 h

 h

 h

  h

& h

j

㓿ۖĀ̊d布替Ĵ瑹ᮽÅ咊

h

h

  hh

ction 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.

                                                                                OMB Control Number: 2060-0482

	   Expiration Date: 6/30/15

EPA Form # 5900-139, Revised 6/12