5900-148 Second-Party Destruction Annual Report

OMB Control Number: 2060-0170
Expiration Date: 4/30/12

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

SECOND-PARTY DESTRUCTION
ANNUAL REPORT (Sec 82.13)

STRATOSPHERIC OZONE PROTECTION PROGRAM

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 a one-time destruction report to
EPA (per Sec 82.13)?

Yes

No

Date Submitted:

1.5 Have you submitted a destruction verification to the
producer or importer (per Sec 82.13)?

Yes

No

Date Submitted:

1.6 Company Information
Company Name

Street Address

City

State

Zip Code

Phone Number

Fax Number

1.7 Company Contact Identification
Reporting Company Contact Person

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 ________________________________________________________________________________
Date

____________________________

Signature ___________________________________________________________________________

SEND COMPLETED FORMS TO:

For U.S. Postal Service:

For Private Courier:

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

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 # 5900-148, Revised 04/09

OMB Control Number: 2060-0170
Expiration Date: 4/30/12

U.S. Environmental Protection Agency
STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE
SECOND-PARTY DESTRUCTION
ANNUAL REPORT (Sec 82.13)

SECTION 2 DESTRUCTION SUMMARY
2.1 Company Name
2.2 Destruction Totals
A

B

Chemical Name

Second-Party Destruction 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 # 5900-148, Revised 04/09