Epa Form 3540 16 – Fill Out and Use This PDF

OMB Control No. 2070-0078

United States Environmental Protection Agency

Instructions for Completing EPA Form 3540-16

Pesticide Report for Pesticide-Producing and Device-Producing Establishments

Reporting Year 2011

It is unlawful to knowingly falsify all or part of any pesticide or device production information

reported on EPA Form 3540-16. (FIFRA §12(a)(2)(M))

General Information

Read all instructions before completing this form. Type or print clearly in dark ink. This form may also be filled out on-line and printed. Page one has space to enter one product. Use the “Add additional page” button at the bottom of the on-line screen-fillable form and add as many pages as necessary to report all products. Each “Additional” page has space for four (4) products. Please make sure you number each page. If you add too many pages, click the “Remove Extra Page” button to remove the last page added. See the Pesticide Establishment Registration and Reporting web page for the instructions and the form. http://www.epa.gov/compliance/monitoring/programs/fifra/establishments.html

1. Who must report?

•All domestic and foreign producing establishments, regardless of whether or not the establishment produced or distributed a pesticide, active ingredient or device must submit a report. (FIFRA §§ 7 and 17)

•Establishments with zero production or distribution in 2011. If your establishment did not produce or distribute products subject to this report in 2011:

O Complete Items 1-27 and Items 40-43. O Check “No” in Item 14.

•Establishments that closed, went out of business or ceased production. O Report all production and distribution during 2011.

O See Number 7 for information on terminating your establishment’s registration.

2. Definitions

OProducer—any person, as defined by FIFRA, “who produces any pesticide, active ingredient, or device (including packaging, repackaging, labeling and relabeling).” (40 CFR §167.3)

OProduce—“manufacture, prepare, propagate, compound or process any pesticide, including any pesticide product pursuant to FIFRA §5, any active ingredient or device, or to package, repackage, label, relabel or otherwise change the container of any pesticide or device.” (40 CFR §167.3)

OEstablishment—Includes:

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OAny site where a pesticidal product, active ingredient or device is produced.

OSites that are independently owned or operated regardless of whether such site is domestic and producing a pesticidal product for export only or whether the site is foreign and producing a pesticidal product for import into the United States.

(40 CFR §167.3)

OSites that produce a pesticidal product for use under an Experimental Use Permit, FIFRA Section 18 Emergency Exemption or Section 24(c) Special Local Needs registration, must report. (40 CFR §167.20)

OSites that produce unregistered pesticidal products for export from the US.

OCustom Blender—any facility that provides the service of mixing registered pesticides to a customer’s specifications, specifically:

O a pesticide-pesticide blend O a pesticide-fertilizer blend

O a pesticide-animal feed mixture

when

Othe blend is not held in inventory

Othe pesticide used in producing the blend bears labeling that does not prohibit the use of the pesticide in the blend

Othe blend is delivered to the end-user with a copy of the labeling of the pesticide used in producing the blend and a statement specifying the composition of the mixture

If these conditions are not met, the establishment does not meet the definition of "custom blender" and must comply with FIFRA Section 7 requirements.

NOTE: A facility where only custom blending activities take place is not considered a pesticide-producing establishment and therefore does not need to be registered. Please see the Pesticide Establishment Registration and Reporting FAQ for more information. http://compliance.supportportal.com/link/portal/23002/23009/ArticleFolder/1654/Pesticide- Producers

3. What must be reported?

•Each producer operating an establishment must submit the following information for each pesticide, active ingredient or device produced at your establishment: (Please note that production and distribution of unregistered pesticides must be reported. See 40 CFR § 152.30).

O Types and amounts produced in 2011.

O Types and amounts sold or distributed in 2011, regardless of when the product was produced.

O An estimate of the amount expected to be produced in 2012.

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•DO NOT REPORT:

O Production, distribution or sale of products NOT produced or repackaged by your establishment (e.g., no changes are made to the product formulation, container or label).

O Products shipped from your supplier directly to your customer. O Any products for which Items 36, 37 and 38 are zero.

O Pesticides that are applied by your staff. O Custom-blended products.

4. When to report:

•Annual Reports are due: On or before March 1, 2012, even if there has been no production.

•Initial Reports: FIFRA §7 requires all registered establishments to submit an initial report to the U.S. EPA 30 days after receipt of notification of establishment registration.

5. Completing the Report:

•Enter the company official’s or authorized agent’s Name and Title (Items 40 & 41).

•An original signature of a company official or authorized agent is required on the report in Item 42.

•Enter the date in Item 43.

•For all pages complete at the bottom: “This is Page _____ of _____.”

•Submit completed reports as directed on Page 9. Please make a copy of the report for your records.

•EPA will not accept any copies (xeroxed, faxed or electronic document formats) of the initial or annual reports.

6. What if I fail to file the production report?

•Failure to file the initial or annual report is an unlawful act and may result in civil penalties up to $7,500 per violation or termination of the establishment’s registration.

7.How to inactivate an establishment’s registration:

•Send a letter on company letterhead with this report stating the establishment is out of business or has ceased production of pesticides, active ingredients or devices requesting that an establishment number be inactivated.

•If EPA terminates your domestic establishment registration, it is illegal to sell or distribute any pesticide, active ingredient or device in the United States or to export a product out of the United States. If EPA terminates your foreign establishment registration, it is illegal for you to import any pesticide, active ingredient or device into the United States.

8.Additional Information is available at Pesticide Establishment—Registration and Reporting Questions at: http://compliance.supportportal.com/link/portal/23002/23009/ArticleFolder/1654/Pesticide- Producers

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General Instructions

Establishment Information: (Items 1 through 14)

NOTE: For items 5, 9, 18 and 22—Foreign country abbreviation codes are available at: http://www.epa.gov/compliance/resources/publications/monitoring/fifra/fgnestablishments.html Please contact U.S. EPA Headquarters 011-202-564-4203 if you do not see the appropriate country code listed. http://compliance.supportportal.com/link/portal/23002/23009/ArticleFolder/1654/Pesticide- Producers

•Item 1—Establishment Name: Enter the producing establishment name.

•Item 2—Establishment Number: Enter the producing establishment number.

•Item 3 to 6—Establishment Site Address: Enter the SITE address, not a post office box or route number, where your establishment is located. For foreign establishments, zip code is equivalent to postal code, post code or postcode.

•Item 7 to 10—Establishment Mailing Address: Enter the mailing address for the establishment if different from the site address.

•Item 11—Telephone Number: Enter the phone number for the establishment. For foreign establishments, please provide the country code.

•Item 12—Email: Enter your email address.

•Item 13—If the establishment name or site address has changed from the previous year, enter a check (X) in the box.

•Item 14— Did you produce or distribute in 2011? Check the appropriate box.

Note: If you checked the “No” box, do not fill in items 28 through 39.

Company Information: (Items 15 through 27)

•Item 15—Company Name: Enter the company name.

•Item 16 to 19—Company Site Address: Enter the company’s headquarter address.

•Item 20 to 23—Company Mailing Address: Enter the mailing address for the company if different from the company site address.

•Item 24—Telephone Number: Enter the phone number for the company. For foreign companies, please provide the country code.

•Item 25—Email: Enter your email address.

•Item 26—If company name or site address has changed from the previous year, enter a check (X) in the box.

•Item 27 — If Authorized Agent name or mailing address has changed from the previous year, enter a check (X) in the box. Please attach your company’s request to change the authorized agent on company letterhead and send to the appropriate EPA office listed on Page 9.

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Pesticide Production Information: (Items 28 through 39)

NOTE: Foreign Establishments – You must report production for products exported to or marketed in the United States. If your establishment produced a pesticide, active ingredient or device and sold some of the product in countries other than the United States, do not report this portion of your production and distribution. For example, if you produce 10,000 pounds of a product and sell 9,000 pounds to other countries and 1,000 pounds to the United States; you should report 10,000 pounds produced and 1,000 distributed into the United States.

•Item 28—Product Code:

O Enter 1 — if product is registered with EPA. O Enter 2 — if product registration is pending.

O Enter 3 — if product is an Experimental Use Permit. O Enter 4 — if product is a device.

O Enter 5 — if product is a Special Local Need (SLN) registration.

O Enter 6 — if product is an Unregistered Pesticide. Attach the formulation of the product to the end of the report showing the product’s active and inert ingredients; their common names; their CAS Registry numbers (if available); and the percentage, by weight, of each ingredient (must total 100%). Multiple formulations may appear on the same page; clearly identify each by product name.

•Item 29—EPA Product Registration Number Information:

OProduct Code 1— Enter EPA Registration No. (as it appears on product label)

(See NOTE below on reporting production of multiple distributor registrations).

OProduct Code 2 — Enter EPA File Symbol assigned to product.

OProduct Code 3 — Enter the Experimental Use Permit number.

OProduct Code 4 — For devices, leave Item 29 blank.

OProduct Code 5 — For stand-alone SLN Registrations, enter the SLN registration number in Item 29 (e.g., SLN-CA-890022). A “stand-alone” SLN is one for which there are no uses other than the 24(c) uses.

OProduct Code 6 — For Unregistered Pesticides, leave Item 29 blank.

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NOTE: Reporting Distributor Registrations—If you produce multiple pesticide products under the same basic EPA registration number (such as distributor products):

Report the total quantities for all distributor products under the basic EPA registration number, and following the product name add “and supplementals.” On a separate paper, list the basic registration number with each distributor company number and brand name and attach it to the report.

•Item 30—Product Name:

List the most common brand name. If marketed under alternate brand names (ABN), add “ABN” and report total production under all names for the formulation.

•Item 31—Product Classifications: Enter the code that best describes the product’s use.

O Classification for Devices 51 Device

OClassifications for Pesticides

04	Insect Repellant	07	Antimicrobial	09	Attractant
18	Sterilizer	20	Disinfectant	21	Sanitizer
27	Fungicide	28	Nematocide	29	Fumigant
34	Herbicide	36	Defoliant	37	Desiccant
38	Antifoulant	43	Insecticide	49	Plant Growth Regulator
54	Rodenticide	57	Animal Repellant	59	Algaecide
61	Molluscicide (e.g. slug bait)	69	Water Purifier

99Multi-Use Active Ingredient (Chemicals that have both pesticidal and non-pesticidal uses). These chemicals do not have an EPA Reg. No. (This classification is rarely appropriate. Producers are required to register both the product and their establishment(s) and report production on an annual basis under FIFRA §7, if a producer has actual or constructive knowledge that a chemical or substance they produce is used or intended for use as an active ingredient in the manufacture of a pesticide. These producers are required to report only the amount of the chemical or substance manufactured and distributed or sold for pesticidal purposes.

•Item 32—Product Type:

O Enter 1 — Technical formulations or active ingredient for Manufacturing Use Only products.

O Enter 2 — End-use product (this includes products where the formulation has been blended, diluted, or changed).

O Enter 3 — Repackaged or relabeled (does not include any blending, dilution or change in the formulation).

O Enter 4 — Device.

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•Item 33—Market Sold or Distributed To:

O Enter 1 — if all the product was marketed in the United States.

O Enter 2 — if the product was marketed both in the United States and exported from the United States.

O Enter 3 — if all the product was exported from the United States.

•Item 34—RUP Status:

O Enter 1 — Product label states RESTRICTED USE PESTICIDE at the top of the front label panel.

O Enter 2 — All other products.

•Item 35—Unit of Measurement:

O	G = Gallons	(liquid chemical product)
O	K = Kilograms	(dry, solid, liquid or gaseous chemical product)
O	L = Liters	(liquid chemical product)
O	P = Pounds	(dry, solid, liquid or gaseous chemical product)
O	T = Tons	(short ton = 2,000 lbs. or 907.2 kilograms) (dry, solid or gaseous
		chemical product)
O	U = Units	(devices and pesticides that the label does not declare as gallons, pounds,
		liters, kilograms or tons)

•Item 36—Amount Produced in 2011:

O Do not include amounts that are custom blended, placed directly into application equipment, or applied to a crop, commodity or site by your staff.

O Round all quantities to the nearest whole number.

•Item 37—Amount Sold or Distributed in 2011 - United States:

O Enter only those products sold or distributed that were produced by your establishment, regardless of when the product was produced.

O Do not include amounts that are custom blended, placed directly into application equipment, or applied to a crop, commodity or site by your staff.

O Foreign producers should enter only the amount of product or number of devices exported to the United States.

O Round all quantities to the nearest whole number.

•Item 38—Amount Sold or Distributed in 2011 to Foreign Markets (Exported):

O Enter the quantity exported from the United States in 2011, regardless of when the product was produced.

O Round all quantities to the nearest whole number. O Foreign establishments enter “0” in Item 38.

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•Item 39—Amount (Estimated) to be Produced in 2012:

O Enter an estimate of the quantity to be produced in 2012.

O Round all quantities to the nearest whole number.

Signature Certification: (Items 40 through 43)

•Items 40 and 41—Name and Title of Company Official or Authorized Agent: Please enter the name and title of the person who is responsible for your establishment’s compliance with the requirements of FIFRA §7. Note: If you are the authorized agent submitting this report, please enter your name and title.

•Items 42 and 43—Signature of Company Official or Authorized Agent: The company official and/or authorized agent listed in Item 40 must sign and date the report in order for it to be complete.

Confidentiality. Under FIFRA §7(d) [7 USC §136e], information reported in Items 36, 37, 38 and 39 of EPA Form 3540-16 will be treated as business confidential, subject to the provisions of FIFRA §10 [7 USC §136h]. You are not required to assert a claim of confidentiality for this information.

If you wish to assert a claim of confidentiality for other information you have provided on this form, you must identify by the box number(s) information for which you are asserting a claim of confidentiality. Information so designated will be disclosed by the EPA only to the extent allowed by, and by means of, the procedures set forth in 40 CFR Part 2. If you do not claim the information as confidential upon submission of the report, it may be made available to the public without further notice to you.

Public Reporting Burden. The time required to complete this report is estimated to average one hour and 26 minutes, per response, including reviewing instructions, searching data sources, gathering and maintaining data needed, and completing review and collection of information. Send comments regarding this burden estimate or other aspects related to this information collection, including suggestions for reducing this burden, to: Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, DC 20460. Include the OMB control number in any correspondence. Do not send the completed 3540-16 form to the above address.

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		Where to Submit Reports
	DOMESTIC PRODUCERS:	Submit reports to the following EPA Regional Office where your company
		headquarters is located.
			States/Terr.			States/Terr.
	EPA Regional Offices		Covered		EPA Regional Offices	Covered
	U.S. EPA Region 1		CT, MA		U.S. EPA Region 6	AR, LA
	Kan Tham		ME, NH		Chuck Ruple	NM, OK
	Toxics and Pesticides Unit (OES 05-4)		RI, VT		Pesticides Section (6PD-P)	TX
	5 Post Office Square, Suite 100				1445 Ross Avenue
	Boston, MA 02109-3912				Dallas, TX 75202-2733
	Telephone: 617-918-1872				Telephone: 214-665-6534
	U.S. EPA Region 2		NJ, NY		U.S. EPA Region 7	IA, KS
	Michael Kramer		PR, VI		Delbert Kelley	MO, NE
	Pesticides Team (MS-500)				Pesticides Section (WWPD/TOPE/PEST)
	2890 Woodbridge Avenue				901 N. 5th Street
	Edison, NJ 08837-3679				Kansas City, KS 66101-2798
	Telephone: 732-321-6610				Telephone: 913-551-7371
	U.S. EPA Region 3		DC, DE		U.S. EPA Region 8	CO, MT
	Kyla Townsend-McIntyre		MD, PA		Kathleen Craig	ND, SD
	Pesticides and Asbestos Programs Branch (3LC62)		VA, WV		Enforcement Division (8ENF-PJ)	UT, WY
	1650 Arch Street				1595 Wynkoop
	Philadelphia, PA 19103-2029				Denver, CO 80202
	Telephone: 215-814-2045				Telephone: 303-312-6049
	U.S. EPA Region 4		AL, FL		U.S. EPA Region 9	AZ, CA
	Mary Summers		GA, KY		Glenda Dugan	GU, HI
	Chemical Products & Asbestos Section		MS, NC		Pesticides Office (CED-5)	MP, NV
	61 Forsyth Street, SW 12th Floor		SC, TN		75 Hawthorne Street
	Atlanta, GA 30303				San Francisco, CA 94105-3901
	Telephone: 404-562-8997				Telephone: 415-947-4204
	U.S. EPA Region 5		IL, IN		U.S. EPA Region 10	AK, ID
	Pesticide Reports Contact		MI, MN		Erin Williams	OR, WA
	Pesticides & Toxics Compliance Section (LC-8J)		OH, WI		Pesticides and Toxics Unit (OCE-084)
	77 West Jackson Boulevard				1200 Sixth Avenue, Suite 900
	Chicago, IL 60604				Seattle, WA 98101-1128
	Telephone: 312-886-7061				Telephone: 206-553-4627
	FOREIGN PRODUCERS:	Submit reports to the following EPA Washington, DC address:
	U.S. Postal Service Mail Address			Courier Delivery Address
	Michelle Stevenson			Michelle Stevenson
	U.S. Environmental Protection Agency			U.S. Environmental Protection Agency
	Pesticides, Waste & Toxics Branch (2225A)			Pesticides, Waste & Toxics Branch
	1200 Pennsylvania Avenue, NW			Ariel Rios Building -- South
	Washington, DC 20460-0001 USA			1200 Pennsylvania Avenue, NW, Room 6102
	Telephone: 202-564-4203			Washington, DC 20004 USA

NOTE: The Agency does not notify you when your report is received. To ensure the Agency receives the report, you may wish to send it by certified or registered mail, return receipt requested.

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