5900-149 Exporter Annual Report

Recordkeeping and Periodic Reporting of the Production, Import, Export, Recycling, Destruction, Transhipment, and Feedstock Use of Ozone-Depleting Substances (Renewal)

Exporter_ClassI

Recordkeeping and Periodic Reporting of the Production, Import, Export, Recycling, Destruction, Transhipment, and Feedstock Use of Ozone-Depleting Substances (Renewal)

OMB: 2060-0170

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OMB Control Number: 2060-0170

Expiration Date: 6/30/15

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:

U.S. EPA
Stratospheric Protection Division
Office of Atmospheric Programs
Mail Code: 6205T
1200 Pennsylvania Avenue, N.W.
Washington, DC 20460

For Private Courier:

U.S. EPA

Tracking System Program Manager

Stratospheric Protection Division
William Clinton East Building, Room 1340

1201 Constitution Avenue, N.W.

Washington, DC 20004


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

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      

Class I Substance Exported      

Quantity of Class I Substance Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Select one: New

Used

Select one:

Transformation

Global Laboratory-Use

Other Essential-Use

Destruction

Halon Aircraft Bottles

TRANSACTION #

     

Recipient Company Name      

Street Address      


City      

Country      

Postal Code      

Company Contact Person      

Phone Number      

Fax Number      

Class I Substance Exported      

Quantity of Class I Substance Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Select one: New

Used

Select one:

Transformation

Global Laboratory-Use

Other Essential-Use

Destruction

Halon Aircraft Bottles

TRANSACTION #

     

Recipient Company Name      

Street Address      


City      

Country      

Postal Code      

Company Contact Person      

Phone Number      

Fax Number      

Class I Substance Exported      

Quantity of Class I Substance Exported (kg)      

Date of Export (mm/dd/yy)      

Port of Export from the U.S.      

Select one: New

Used

Select one:

Transformation

Global Laboratory-Use

Other Essential-Use

Destruction

Halon Aircraft Bottles

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 5/15

File Typeapplication/msword
AuthorGrace Lange
Last Modified ByJette, Gabrielle
File Modified2015-07-10
File Created2015-07-10

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