5900-156 Notification of Transfers of Art 5 Allowances, Essential

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

NOTIFICATION OF TRANSFERS OF ARTICLE 5
ALLOWANCES, ESSENTIAL-USE ALLOWANCES, OR
ESSENTIAL-USE CFCS

STRATOSPHERIC OZONE PROTECTION PROGRAM

(Sec 82.12)

SECTION 1

TRANSFEROR/TRANSFEREE IDENTIFICATION

1.1 Date of Submission

1.2

1.3 Number of Transactions
Reported

1.4 Number of Pages
Submitted

Original Submittal

Re-submittal

1.5 Company Information
Company Type (Select only one)

Transferor (for Transfers of Article 5 or Essential-Use Allowances)
Transferee (for Transfers of Essential-Use CFCs)

Company Name

Street Address

City

State

Zip Code

1.6 Company Contact Identification
Reporting Company Contact Person

Phone Number

Fax Number

E-mail Address

1.7 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 # 5900-156, Revised 04/09

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

NOTIFICATION OF TRANSFERS OF ARTICLE 5
ALLOWANCES, ESSENTIAL-USE ALLOWANCES, OR
ESSENTIAL-USE CFCS

STRATOSPHERIC OZONE PROTECTION PROGRAM

(Sec 82.12)

SECTION 2.A

TRANSACTION RECORD FOR TRANSFERS OF ARTICLE 5 (A5) ALLOWANCES
OR ESSENTIAL-USE ALLOWANCES
(Reproduce additional sheets as needed)
TRANSACTION #

2.1 Transferee Identification
Transferee Company Name

Transferee Contact Person

Street Address

City

State

Zip Code

Phone Number

Fax Number

E-mail Address

Are Article 5 allowances or essential-use allowances being transferred?
2.2 Control Period for which Allowances Are Being
Transferred (select only one)

2.3 Chemical Transferring From

Article 5

Essential Use

Current Year Allowances

Baseline Year Allowances

2.4 ODP

2.5 Amount of Allowances of Chemical in Section 2.3
Being Transferred (kg)
2.6 Calculated Level of Chemical in Section 2.3 Being
Transferred (Section 2.4 x Section 2.5)
2.7 Chemical Transferring To

2.8 ODP

2.9 Amount of Offset (0.01 x Section 2.5) (kg)
2.10 Amount of Allowances Subtracted from
Transferor’s Balance of Chemical Being
Transferred (Section 2.5 + Section 2.9) (kg)
2.11 Amount of Allowances of Chemical in Section 2.7
Being Received (Section 2.6 ÷ Section 2.8) (kg)
2.12 For Essential-Use Allowance transfers, have you included signed documentation from the
transferee identifying the CFC MDI products that will be produced using the Essential-Use
Allowances (per Sec 82.12)?

EPA Form # 5900-156, Revised 04/09

Yes

No

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

NOTIFICATION OF TRANSFERS OF ARTICLE 5
ALLOWANCES, ESSENTIAL-USE ALLOWANCES, OR
ESSENTIAL-USE CFCS

STRATOSPHERIC OZONE PROTECTION PROGRAM

(Sec 82.12)

SECTION 2.B

TRANSACTION RECORD FOR TRANSFERS OF ESSENTIAL-USE CFCS
(Reproduce additional sheets as needed)

TRANSACTION #
2.1 Transferor Identification
Transferor Company Name

Transferor Contact Person

Street Address
City

State

Phone Number

Fax Number

Zip Code

E-mail Address

2.2 Essential-Use CFC being transferred (select only one)

CFC-11

CFC-12

2.3 Amount of Essential-Use CFC in Section 2.2 being
transferred (kg)
2.4 The specific Metered Dose Inhaler (MDI) products (i.e.
the MDI drug product or active moiety) that the
Transferee plans to produce with the transferred CFCs
2.5 The country(ies) where the CFC MDIs produced with
the transferred Essential-Use CFCs will be sold if other
than in the United States
2.6 Have you provided certification that the Essential-Use CFCs will be
used in the production of essential MDIs (per Sec 82.12)?

Yes

No

2.7 Have you submitted a letter by the transferor stating that it concurs
with the terms of the transfer stated in your request (per Sec 82.12)?

Yes

No

EPA Form # 5900-156, Revised 04/09

CFC-114

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

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

NOTIFICATION OF TRANSFERS OF ARTICLE 5
ALLOWANCES, ESSENTIAL-USE ALLOWANCES, OR
ESSENTIAL-USE CFCS

STRATOSPHERIC OZONE PROTECTION PROGRAM

(Sec 82.12)

SECTION 3

UNEXPENDED BALANCE SUMMARY

3.1 Balance of Unexpended Allowances Prior to Transfers Reported
A

B

C

Chemical Name

Balance of Unexpended Article 5
Allowances

Balance of Unexpended Essential-Use
Allowances for CFC use in Essential MDIs

CFC-11
CFC-12
CFC-13
CFC-111
CFC-112
CFC-113
CFC-114
CFC-115
Other CFCs (please specify)

EPA Form # 5900-156, Revised 04/09