Form 3520-12A Fuel Manufacturer Annual Report for Motor Vehicle Gasoli

EPA Form 3520-12A (08-2003) - Fuel Manufacturer Annual Report for Motor Vehicle Fuel

Page 1 of 2

U.S. Environmental Protection Agency
Office of Transportation and Air Quality

Form Approval
OMB No. 2060-0150
Approval Expires 01/31/2004

Fuel Manufacturer Annual Report
for Motor Vehicle Gasoline or Diesel Fuel

Leave Blank

1. Company Name:

1a. Company ID:

2. Address:

3. Fuel ID:
4. Report Year:

5. Brand name of the motor vehicle fuel covered by this report:
6. Fuel properties, to the extent known:
Percent by weight
Highest
(a) Aromatics (Diesel Only)
(b) Olefins (Diesel Only)
(c) Saturates (Diesel Only)
(d) Polynuclear Organic Material
(e) Sulfur (Diesel Only)
(f) Trace Elements

Gasoline:
(g) Distillation: 10% Point (°C)
(h) Distillation: End Point (°C)
(i) Research Octane Number
(j) Motor Octane Number
Diesel Fuel:
(k) Distillation: 90% Point (°C)
(l) Distillation: End Point (°C)
(m) Cetane Number or Index

Lowest

Methods of Analysis
Same as previously reported:
c Yes g
d
e
f
g
c No
d
e
f
Average
If "No", identify below or on a seperate sheet.

EPA Form 3520-12A (08-2003) - Fuel Manufacturer Annual Report for Motor Vehicle Fuel
7.

For any additive that you reported you may use, do you have any information, not previously reported, concerning the
mechanisms of action of the additive; reactions between the additive and gasoline or diesel fuel; the identification and
measurement of the emission products of the additive when used in gasoline or diesel fuel; the effects of the additive on all
emissions; the toxicity and any other public health or welfare effects of the emission products of the additive; and/or, for
gasoline only, the effects of the emission products of the additive on the performance of emission control devices/systems?

c
d
e
f
g

8.

No

c
d
e
f
g

Yes If "Yes," attach separate sheet(s) providing summaries of such information and a
description of the test procedures used in obtaining the information.
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 6 and/or 7?

c
d
e
f
g

9.

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No

c
d
e
f
g

Yes

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

Item 6:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 7:

c
d
e
f
g

Yes

c
d
e
f
g

No

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 (print):

Title:

Telephone:

Fax:

E-mail:

Comments:

Mail the completed form to:
U.S. Environmental Protection Agency
Attn: Fuel Registration/Suite L-103
Mail Code - 6406J
1200 Pennsylvania Avenue, NW
Washington, DC 20460-0001
Telephone (202) 564-9754
Fax (202) 565-2153
email: caldwell.jim@epa.gov, fernandes.joseph@epa.gov
This office is operated by a contractor for the EPA.

or, via courier:
U.S. Environmental Protection Agency
Attn: Fuel Registration/Suite L-103
Mail Code - 6406J
501 Third Street, NW
Washington, DC 20001