5900-150 Importer Quarterly Report

OMB Control Number: 2060-0170

Expiration Date: 4/30/12

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance importer quarterly report (Sec 82.13)

SECTION 1 IMPORTING COMPANY IDENTIFICATION

1.1 Date of Submission

     ions Reported

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

1st

2nd

3rd

4th

Year      

1.6 Importing Company

Company Name      

Street Address      

City      

State      

Zip Code      

Importer Number      

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 importer quarterly report (Sec 82.13)

SECTION 2 TRANSACTION RECORDS (Reproduce additional sheets as needed)

2.1 Company Name

     

2.2 Transaction Summaries

TRANSACTION #

     

Source Country      

Quantity of Commodity Imported (kg)      

Class I Substance Imported      

Quantity of Class I Substance Imported (kg)      

Port of Entry into the U.S.      

Date of Import (mm/dd/yy)      

Customs Entry Summary Number      

Transaction Type (select one):

New

Used

Heels

If New:

Transformation

Destruction

Global Lab Essential-Use

Other Essential-Uses (i.e., MDIs)

If Used:

Transformation

Destruction

Halon Aircraft Bottles

Other Use; Date of Non-Objection Notice (mm/dd/yy)       

If Heels, it will:

Remain in Container and Be Included in Future Shipment

Be Recovered and Transformed

Be Recovered and Destroyed

Be Recovered for a Non-emissive Use

TRANSACTION #

     

Source Country      

Quantity of Commodity Imported (kg)      

Class I Substance Imported      

Quantity of Class I Substance Imported (kg)      

Port of Entry into the U.S.      

Date of Import (mm/dd/yy)      

Customs Entry Summary Number      

Transaction Type (select one):

New

Used

Heels

If New:

Transformation

Destruction

Global Lab Essential-Use

Other Essential-Uses (i.e., MDIs)

If Used:

Transformation

Destruction

Halon Aircraft Bottles

Other Use; Date of Non-Objection Notice (mm/dd/yy)       

If Heels, it will:

Remain in Container and Be Included in Future Shipment

Be Recovered and Transformed

Be Recovered and Destroyed

Be Recovered for a Non-emissive Use

TRANSACTION #

     

Source Country      

Quantity of Commodity Imported (kg)      

Class I Substance Imported      

Quantity of Class I Substance Imported (kg)      

Port of Entry into the U.S.      

Date of Import (mm/dd/yy)      

Customs Entry Summary Number      

Transaction Type (select one):

New

Used

Heels

If New:

Transformation

Destruction

Global Lab Essential-Use

Other Essential-Uses (i.e., MDIs)

If Used:

Transformation

Destruction

Halon Aircraft Bottles

Other Use; Date of Non-Objection Notice (mm/dd/yy)       

If Heels, it will:

Remain in Container and Be Included in Future Shipment

Be Recovered and Transformed

Be Recovered and Destroyed

Be Recovered for a Non-emissive Use

U.S. Environmental Protection Agency stratospheric ozone protection program							class i controlled substance importer quarterly report (Sec 82.13)
SECTION 3		COMPANY IMPORT DATA
3.1 Company Name		     
3.2 Company Import Totals (kg)
A	B		C	D	E	F	G	H		I
Chemical Name (Commodity Code)	Essential-Uses		In-House Transformation	Second-Party Transformation	In-House Destruction	Second-Party Destruction	Gross Imports of Class I Substance (B+ C+ D+ E+ F= G)	Imports of “Used” Class I Substance		Import of Class I “Heels”
	Global Laboratory Exemption	Other Essential-Use Exemption (i.e., MDIs)
CFC-11 (2903.41.0000)	     	     	     	     	     	     	     	     		     
CFC-12 (2903.42.0000)	     	     	     	     	     	     	     	     		     
CFC-13 (2903.45.0000)	     	     	     	     	     	     	     	     		     
CFC-111 (2903.45.0000)	     	     	     	     	     	     	     	     		     
CFC-112 (2903.45.0000)	     	     	     	     	     	     	     	     		     
CFC-113 (2903.43.0000)	     	     	     	     	     	     	     	     		     
CFC-114 (2903.44.0010)	     	     	     	     	     	     	     	     		     
CFC-115 (2903.44.0020)	     	     	     	     	     	     	     	     		     
Other CFCs and Commodity Code (specify)            	     	     	     	     	     	     	     	     		     
           	     	     	     	     	     	     	     	     		     
HBFCs (2903.49.9060) (specify)      	     	     	     	     	     	     	     	     		     
     	     	     	     	     	     	     	     	     		     
Halons (2903.46.0000) (specify)      	     	     	     	     	     	     	     	     		     
Carbon Tetrachloride (2903.14.0000)	     	     	     	     	     	     	     	     		     
Methyl Chloroform (2903.19.6010)	     	     	     	     	     	     	     	     		     
CBM (2903.49.1000)	     	     	     	     	     	     	     	     		     

EPA Form # 5900-150, Revised 11/11