5900-152 Laboratory Certification Report

OMB Control Number: 2060-0170

Expiration Date: 6/30/15

U.S. Environmental Protection Agency stratospheric ozone protection program			class i controlled substance laboratory certification report (Sec 82.13)
SECTION 1	LABORATORY IDENTIFICATION
1.1 Date of Submission		     	1.2 Original Submittal Re-submittal
1.3 Number of Class I Substances Reported		     	1.4 Number of Pages Submitted	     
1.5 Laboratory Information
Laboratory Name      
Street Address      
City      		State      	Zip Code      
1.6 Laboratory Contact Identification
Reporting Laboratory Contact Person      		Phone Number      	Fax Number      
E-mail Address      
1.7 Signature of Reporting Laboratory Representative
I certify that the quantities of controlled substances listed in this form are purchased solely for use in laboratory applications and will not be resold or used in manufacturing. 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:

The Company from Whom the Class I Substances Were Purchased

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 2.1 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 laboratory certification report (Sec 82.13)

SECTION 2

SUBSTANCE IDENTIFICATION AND USE (Reproduce Additional Sheets as Needed)

2.1 Lab Name

     

2.2 Class I Substance (Select only one below)

CFC-11

CFC-12

CFC-13

CFC-111

CFC-112

CFC-113

CFC-114

CFC-115

Other CFC (please specify)

     

HBFC (please specify)

     

Halon (please specify)

     

Carbon Tetrachloride

Methyl Chloroform

CBM

Methyl Bromide

2.3 Amount of Class I Substance (kg)

     

2.4 Laboratory Applications (Select as many as apply and indicate percent use)

A. Research and Development Reaction Solvent or Reaction Feedstock....................................................... B. Analytical Uses and Regulated Applications Reference Chemical............................................................................................. Toxicant............................................................................................... Product................................................................................................ Extraction Pesticide and Heavy Metal Detection................................................. G ____% Product................................................................................................ Color & Food Additive Detection......................................................... Diluent Zinc, Copper, Cadmium Detection in Plants and Food....................... Microchemical Methods to Determine Molecular Weight of Oxygen... Measuring Drug Purity and Residual Information................................ Sterilization of Lab Equipment............................................................ Carrier (Inert) Forensic Methods................................................................................ Titration............................................................................................... Analytical Equipment........................................................................... Tracer Sanitary Engineering........................................................................... Miscellaneous (Including Testing) Ingredient in Material for Testing........................................................ Separation Media................................................................................ C. Miscellaneous Laboratory Method Development............................................. Sample Preparation Using Solvent...........................................

     %      %      %      %      %      %      %      %      %      %      %      %      %      %      %      %      %      %      %

SECTION 3

SUPPLIER IDENTIFICATION

3.1 Supplier Name

     

EPA Form # 5900-152, Revised 6/12