5900-147 Second-Party Transformation Annual Report

OMB Control Number: 2060-0170

Expiration Date: 12/31/11

U.S. Environmental Protection Agency stratospheric ozone protection program					class i controlled substance second-party transformation annual report (Sec 82.13)
SECTION 1 COMPANY IDENTIFICATION
1.1 Date of Submission	     	1.2 Year To Which This Report Applies				     	1.3 Original Submittal Re-submittal
1.4 Have you submitted an IRS certificate of intent to transform to the producer or importer (per Sec 82.13)?						Yes No		Date Submitted:			     
1.5 Company Information
Company Name      
Street Address      
City      				State      					Zip Code      
1.6 Company Contact Identification
Reporting Company Contact Person      			Phone Number      					Fax Number      
E-mail Address      
1.7 Signature of Reporting Company Representative
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.
Name       Title       Signature      										Date      

SEND COMPLETED FORMS TO:

For U.S. Postal Service: Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenue, NW Washington, DC 20460

For Private Courier: Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1310 L Street, NW; 10th Floor Washington, DC 20005

Information in reports submitted in compliance with the final rule may be claimed as confidential. A company may assert a claim of confidentiality for information submitted by clearly marking that information as confidential. Such information shall be treated in accordance with EPA’s procedures for information claimed as confidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confidentiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2.203).

The public reporting and recordkeeping burden for this collection of information is estimated to average 2.4 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.

U.S. Environmental Protection Agency stratospheric ozone protection program			class i controlled substance second-party transformation annual report (Sec 82.13)
SECTION 2 TRANSFORMATION SUMMARY
2.1 Company Name	     
2.2 Transformation Totals
A		B
Chemical Name		Second-Party Transformation of Class I Substance (kg)
CFC-11		     
CFC-12		     
CFC-13		     
CFC-111		     
CFC-112		     
CFC-113		     
CFC-114		     
CFC-115		     
Other CFCs (please specify)      		     
     		     
     		     
HBFCs (please specify)      		     
     		     
     		     
Halons (please specify)      		     
     		     
     		     
Carbon Tetrachloride		     
Methyl Chloroform		     
CBM		     

EPA Form # 5900-147, Revised 08/08