5900-153 Essential Use Allowance Holders & Laboratory Supplier Qu

OMB Control Number: 2060-0170

Expiration Date: 12/31/11

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance essential use allowance holders & laboratory supplier quarterly report and essential use allowance holder annual report (Sec 82.13)

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission

     

1.2 Original Submittal Re-submittal

1.3 Number of Transactions Reported

     

1.4 Number of Pages Submitted

     

1.5 Quarter and Year to Which This Report Applies (If 4th quarter is selected, Essential Use Holders should also submit Section 5 of this form.)

1st

2nd

3rd

4th

Year       

1.6 Company Information

Company Name      

Street Address      

City      

State      

Zip Code      

1.7 Company Contact Identification

Reporting Company Contact Person      

Phone Number      

Fax Number      

E-mail Address      

1.8 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 essential use allowance holders & laboratory supplier quarterly report and essential use allowance holder annual report (Sec 82.13)
SECTION 2	QUARTERLY REPORT: For Essential-Use Allowance Holders and Distributors of Laboratory Supplies: Amounts Purchased/Received from Producers and/or Importers (Reproduce additional sheets as needed)
2.1 Company Name		     
2.2 Transaction Summaries
TRANSACTION #				     
Source Company      
Street Address      
City      			State (U.S.) or Country      				Zip Code (U.S.)      
Chemical Name of Class I Substance Purchased/Received      					Quantity of Class I Substance Purchased/Received (kg)      
TRANSACTION #				     
Source Company      
Street Address      
City      			State (U.S.) or Country      				Zip Code (U.S.)      
Chemical Name of Class I Substance Purchased/Received      					Quantity of Class I Substance Purchased/Received (kg)      
TRANSACTION #				     
Source Company      
Street Address      
City      			State (U.S.) or Country      				Zip Code (U.S.)      
Chemical Name of Class I Substance Purchased/Received      					Quantity of Class I Substance Purchased/Received (kg)      

U.S. Environmental Protection Agency stratospheric ozone protection program					class i controlled substance essential use allowance holders & laboratory supplier quarterly report and essential use allowance holder annual report (Sec 82.13)
SECTION 3	QUARTERLY REPORT: For Distributors of Laboratory Supplies: Amounts Supplied to Each Laboratory Customer Quarterly (Reproduce additional sheets as needed)
3.1 Company Name		     
3.2 Quarterly Totals by Lab Customer
Amounts Supplied Quarterly per Lab
Lab Company      
Street Address      
City      			State      			Zip Code      
Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       				Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       
Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       				Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       
Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       				Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       
Amounts Supplied Quarterly per Lab
Lab Company      
Street Address      
City      			State      			Zip Code      
Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       				Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       
Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       				Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       
Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       				Class I Substance Supplied to Lab and Quantity: Substance:        Quantity (kg):       

U.S. Environmental Protection Agency stratospheric ozone protection program				class i controlled substance essential use allowance holders & laboratory supplier quarterly report and essential use allowance holder annual report (Sec 82.13)
SECTION 4	QUARTERLY TOTALS BY CHEMICAL
4.1 Company Name		     
4.2 Company Totals
A			B		C
Chemical Name			Total Quantity of Essential Use Class I ODS Received from Producers/Importers (kg)		Total Quantity of Class I ODS Supplied to Labs (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			     		     

U.S. Environmental Protection Agency stratospheric ozone protection program								class i controlled substance essential use allowance holders & laboratory supplier quarterly report and essential use allowance holder annual report (Sec 82.13)
SECTION 5		ANNUAL REPORT: For 4th Quarter Essential Use Holder Reporting Only (To be completed by the person allocated Essential-Use Allowances)
5.1 Distributor Name		     
5.2 Company Totals
A	B		C		D	E	F		G	H	I
Chemical Name	Amount Acquired by Production (kg)		Amount Acquired for Essential Uses by Import and Country(s) of Manufacture		Amounts On Hand at the End of the Year (includes pre-1996 amounts) (kg)	Pre-phaseout Stockpiled Amounts Held (kg)	Amounts Used for Essential Uses (kg)		Amount Contained in Exported Products (kg)	Amounts Destroyed or Recycled (kg)	Total Number of Marketable MDI Units Manufactured
			Amount (kg)	Country
CFC-11	     		     	     	     	     	     		     	     	     
CFC-12	     		     	     	     	     	     		     	     
CFC-114	     		     	     	     	     	     		     	     

EPA Form # 5900-153, Revised 08/08