Epa Form 3520 13A – Fill Out and Use This PDF

EPA Form 3520-13A (11-01-2013) - Fuel Additive Manufacturer Annual Report	Page 1 of 2
U.S. Environmental Protection Agency	Form Approval
Office of Transportation and Air Quality	OMB No. 2060-0150
	Approval Expires 10/31/2016
	Leave Blank

* Required Field Fuel Additive Manufacturer Annual Report

* 1a. Company ID:

*1. Company Name:

* 2. Report Year: (Year format:YYYY)	* 3. Report Type: (Check Only One)
			Original			Resubmission

4.For any additive below, do you have information, not previously reported, on the levels of impurities greater than 0.1 percent by weight?

5.For any additive below, do you have information, not previously reported, concerning the mechanisms of action of the additive; reactions between the additive and gasoline and/or diesel fuel; the identification and measurement of the emission products

of the additive when used in gasoline and/or diesel fuel; the effects of the additive on all emissions; the toxicity and any

other public health or welfare effects of the emissions products of the additive; and/or the effects of the emission products of the additive on the performance of emission control devices/systems?

6. Production Values:

EPA Form 3520-13A (11-01-2013) - Fuel Additive Manufacturer Annual Report

Page 2 of 2

*7. 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 items 4, 5 and/or 6?

*

No

Yes

If "Yes," indicate "Yes" or "No" for each item below:

Yes

No

Item 4:

Item 5:

Yes

No

Item 6:

Yes

No

8.Certification

To the best of my knowledge, the above is complete and correct. I am authorized by the manufacturer to submit this information.

Signature:

* Date:

* Name of Signer:

First Name:

Last Name:

Title:

Check if the Contact Person is the same as the signer above.

* Contact Person: First Name:

Last Name:

Title:

* Telephone:

Fax:

(

)

Extension:

E-mail:

Comments

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