5900-149 Exporter Annual Report

OMB Control Number: 2060-0170

Expiration Date: 4/30/12

U.S. Environmental Protection Agency stratospheric ozone protection program							class i controlled substance exporter annual report (Sec 82.13)
SECTION 1 EXPORTING 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 Year to Which This Report Applies:				Year      
1.6 Exporting Company Information
Company Name      
Street Address      
City      	State      							Zip Code      
Exporter EIN from Customs Form 7525      
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.

EPA Form # 5900-149, Revised 11/11

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance exporter annual report (Sec 82.13)

SECTION 2

TRANSACTION RECORDS (Reproduce additional sheets as needed)

2.1 Company Name

     

2.2 Transaction Summaries

TRANSACTION #

     

Recipient Company Name      

Street Address      

City      

Country      

Postal Code      

Company Contact Person      

Phone Number      

Fax Number      

Quantity of Commodity Exported (kg)      

Class I Substance Exported      

Quantity of Class I Substance Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Transaction Type (select one):

New

Used

If New:

Transformation

Destruction

Global Lab Use

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

Produced with Prod/Cons Allowances

If Used:

Transformation

Destruction

Halon Aircraft Bottles

TRANSACTION #

     

Recipient Company Name      

Street Address      

City      

Country      

Postal Code      

Company Contact Person      

Phone Number      

Fax Number      

Quantity of Commodity Exported (kg)      

Class I Substance Exported      

Quantity of Class I Substance Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Transaction Type (select one):

New

Used

If New:

Transformation

Destruction

Global Lab Use

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

Produced with Prod/Cons Allowances

If Used:

Transformation

Destruction

Halon Aircraft Bottles

TRANSACTION #

     

Recipient Company Name      

Street Address      

City      

Country      

Postal Code      

Company Contact Person      

Phone Number      

Fax Number      

Quantity of Commodity Exported (kg)      

Class I Substance Exported      

Quantity of Class I Substance Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Transaction Type (select one):

New

Used

If New:

Transformation

Destruction

Global Lab Use

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

Produced with Prod/Cons Allowances

If Used:

Transformation

Destruction

Halon Aircraft Bottles

EPA Form # 5900-149, Revised 11/11

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance exporter annual report (Sec 82.13)

SECTION 3

COMPANY EXPORT TOTALS (Reproduce additional sheets as needed)

3.1 Company Name

     

3.2 Transaction Summaries

Class I Substance (Commodity Code) (Select only one below)

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 CFC and Commodity Code (specify)

           

HBFC (specify) (2903.49.9060)

     

Halon (specify) (2903.46.0000)

     

Carbon Tetrachloride (2903.14.0000)

Methyl Chloroform (2903.19.6010)

CBM (2903.49.1000)

Country Exported To

Quantity of Class I Substance Exported (kg)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

EPA Form # 5900-149, Revised 11/11