5900-153 Essential use allowance holders & lab supplier quarterly

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY
SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE
ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

STRATOSPHERIC OZONE PROTECTION PROGRAM

SECTION 1 COMPANY IDENTIFICATION
1.1 Date of Submission

1.2

1.3 Number of Transactions
Reported

1.4 Number of Pages
Submitted

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

st

1

Original Submittal

nd

2

rd

Re-submittal

th

3

4

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

SEND COMPLETED FORMS TO:

Date
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)
th
1310 L Street, NW; 10 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 # 5900-153, Revised 04/11

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY
SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE
ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

STRATOSPHERIC OZONE PROTECTION PROGRAM

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

Chemical Name of Class I Substance Purchased/Received

Zip Code (U.S.)

Quantity of Class I Substance Purchased/Received (kg)

TRANSACTION #
Source Company

Street Address

City

State (U.S.) or Country

Chemical Name of Class I Substance Purchased/Received

Zip Code (U.S.)

Quantity of Class I Substance Purchased/Received (kg)

TRANSACTION #
Source Company
Street Address

City

State (U.S.) or Country

Chemical Name of Class I Substance Purchased/Received

EPA Form # 5900-153, Revised 04/11

Zip Code (U.S.)

Quantity of Class I Substance Purchased/Received (kg)

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency
STRATOSPHERIC OZONE PROTECTION PROGRAM

SECTION 3

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY
SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE
ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

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:

Class I Substance Supplied to Lab and Quantity:

Substance:

Substance:

Quantity (kg):

Quantity (kg):

Class I Substance Supplied to Lab and Quantity:

Class I Substance Supplied to Lab and Quantity:

Substance:

Substance:

Quantity (kg):

Quantity (kg):

Class I Substance Supplied to Lab and Quantity:

Class I Substance Supplied to Lab and Quantity:

Substance:

Substance:

Quantity (kg):

Quantity (kg):

Amounts Supplied Quarterly per Lab
Lab Company
Street Address
City

State

Zip Code

Class I Substance Supplied to Lab and Quantity:

Class I Substance Supplied to Lab and Quantity:

Substance:

Substance:

Quantity (kg):

Quantity (kg):

Class I Substance Supplied to Lab and Quantity:

Class I Substance Supplied to Lab and Quantity:

Substance:

Substance:

Quantity (kg):

Quantity (kg):

Class I Substance Supplied to Lab and Quantity:

Class I Substance Supplied to Lab and Quantity:

Substance:

Substance:

EPA Form # 5900-153, Revised 04/11

Quantity (kg):

Quantity (kg):

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY
SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE
ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

STRATOSPHERIC OZONE PROTECTION PROGRAM

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
Methyl Bromide

EPA Form # 5900-153, Revised 04/11

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY
SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE
ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

STRATOSPHERIC OZONE PROTECTION PROGRAM

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

Chemical
Name

Amount
Acquired by
Production (kg)

C

D

E

F

G

H

I

Amount Acquired for Essential
Uses by Import and Country(s)
of Manufacture

Amounts On Hand
at the End of the
Year (includes pre1996 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)
CFC-11
CFC-12
CFC-114

EPA Form # 5900-153, Revised 04/11

Country