Epa Form 3540 1 – Fill Out and Use This PDF

	Part I:	To Be Completed by Importer or Agent
	1. Name and Complete Address of Broker or Agent		2. Name and Complete Address of Importer or Consignee

Return Form to this Address

Return Form to this Address

3. Name and Address of

4. EPA Registration Number

5. EPA Producer Establishment No.

Shipper

6. Brand name of Product

7. Major Active Ingredients and Percentage of Each

8. Unit Size

9. Quantity

10. Total Net Weight

11.

Country of Origin

Carrier

12. Port of Entry

13.

14. Entry Number

15. Entry Date

16.

I assert that information constituting Confidential Business

Information is shown in the above blocks numbered: (Note:

Blocks 4, 5, 6, 7 are not entitled to CBI treatment–see

17. Location of Goods for Examination after Importation

Instructions)

18. Remarks

Certification

I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete.I acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law.

19. Printed Name of Importer or Agent		Telephone Number	20. Signature of Importer or Agent	Date Signed

		Part II: To Be Completed by U.S. Environmental Protection Agency
	Action to be taken by U.S. Customs Service
	Release Shipment		Detain for Inspection	Release shipment to consigne under bond. Shipment must be held
				intact pending inspection.
	Other
	Remarks
	Signature and Title of EPA Official				Date
			Part III: To Be Completed by U.S. Customs Service
	The information shown in Part I		was compared with the entry papers for this shipment and no discrepancies were noted.

The shipment was handled as instructed by EPA in Part II. Any deviations should be brought to the attention of EPA before releasing shipment and should also be noted in "Remarks."

Remarks

Signature of District Director of Customs	Date

EPA Form 3540-1 (Rev. 2-00)

Official File Copy

Instructions

Customs Regulations. 19 CFR 12.112 requires an importer desiring to import pesticides or devices into the United Statesto submit EPA Form 3540-1, Notice of Arrival of Pesticides and Devices, to the U.S. Environmental Protection Agencyprior to the arrival of shipment in the United States. This form will be used by:Importer or Agent. The Importer or his agent must complete Part 1 of the form. It may be necessary to complete some ofthe items at the time of entry, e.g., entry data, carrier. To expedite the handling of pesticides shipments, submit this formto the EPA office listed below having jurisdiction over the state/territory in which the Port of Entry is located prior to thearrival of the shipment.EPA. Part II of this form will be completed by EPA. EPA will retain the EPA Copy for its files and return the other copiesto the importer or agent for presentation to Customs at the time of entry.Customs . Customs will compare the information shown on this form with the entry documents and the shipment. Bringany discrepancies to the attention of EPA before the shipment is released and noted in the remarks section. If theimportation is not handled by Customs in the manner instructed in Part II, this should also be noted in remarks. All dataleft blank by the importer (e.g., entry date) must be completed at this time. After completion of Part III and signing theform, Customs will return the Official File Copy to EPA and retain the Custom's Copy.

The following blocks are self explanatory - 1, 2, 8, 9, 10, 12, 14, 15, 18, 19, and 20.

3.Name and Address of Shipper. The name and address of person exporting the pesticide to the United States.

4.EPA Registration No. The product registration number assigned at the time of registration which identifies the product. If the product is a device, write the word `device' in the block.

5.EPA Producer Establishment No. The producing establishment registration number which identified where the pesticidal product, active ingredient, or device was produced.

6.Brand Name of Product. Name under which the product is sold or distributed.

7.Major Active Ingredients and Percentage of Each. If block 4 contains registration number, leave blank. If no registration number, list active ingredients (or two major ingredients and percentage of each).

11.Country of Origin. The country in which the pesticide producer is located.

13.Carrier. E.g., ship's name, airline or trucking company.

16.Confidential Business Information (CBI) designation. Please note that the information provided in blocks 4, 5, 6, and 7 is not entitled to confidential treatment under section 7(d) of FIFRA and under labeling requirements for pesticides at 40 CFR 156.10. Information provided in those blocks will be made public with no further notice.

17.Location of Goods for Examination after Importation. Enter the EPA establishment number for importing registered establishment in the case of unregistered product imports between establishments operated by the same producer.

EPA Regional Offices	States Covered	EPA Regional Offices	States Covered
EPA Region I	CT MA ME	EPA Region VI	AR LA NM
1 Congress Street (SEA)	NH RI VT	445 Ross Avenue OK TX
Boston, MA 02114-2023		Suite #1200 (6PD-P)
Dallas, TX 75202-2733
EPA Region II	NJ NY	EPA Region VII	IA KS
MS-500, Bldg #5	PR VI	901 N. 5TH Street (PESTWWPD)	MO NE
2890 Woodbridge Ave.		Kansas City, KS 66101
Edison, NJ 08837-3679
EPA Region III	DE DC	EPA Region VIII	CO MT
1650 Arch Street (3WC32)	MD PA	999 18th Street	ND SD
Philadelphia, PA 19103-2029	VA WV	Suite #500 (8ENF/TEP)	UT WY
Denver, CO 80202-2466
EPA Region IV	AL FL GA	EPA Region IX	AZ AS CA
61 Forsyth Street, SW (APT-PS)	KY MS NC	75 Hawthorne Street (CMD-4-3)	GU HI NV
Atlanta, GA 30303-8960	SC TN	San Francisco, CA 94105-3901	PI WK
EPA Region V	IL IN	EPA Region X	AK ID
77 West Jackson Blvd.(DT-8J)	OH MI	1200 Sixth Avenue (ECO-084)	OR WA
Chicago, IL 60604-3507	MN WI	Seattle, WA 98101-9797

EPA Form 3540-1 (Rev. 2-00)