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

OMB Control Number: 2060-0170

Expiration Date: 6/30/15

U.S. Environmental Protection Agency stratospheric ozone protection program					class i controlled substance notification of transfers of article 5 allowances, essential-use allowances, or essential-use cfcs (Sec 82.12)
SECTION 1 TRANSFEROR/TRANSFEREE 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 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       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 notification of transfers of article 5 allowances, essential-use allowances, or essential-use cfcs (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? Article 5 Essential Use
2.2 Control Period for which Allowances Are Being Transferred (select only one)				Current Year Allowances				Baseline Year Allowances
2.3 Chemical Transferring From		     					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)?										Yes No

U.S. Environmental Protection Agency stratospheric ozone protection program				class i controlled substance notification of transfers of article 5 allowances, essential-use allowances, or essential-use cfcs (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      		Zip Code      
Phone Number      								Fax Number      
E-mail Address      
2.2 Essential-Use CFC being transferred (select only one)			CFC-11				CFC-12		CFC-114
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

U.S. Environmental Protection Agency stratospheric ozone protection program			class i controlled substance notification of transfers of article 5 allowances, essential-use allowances, or essential-use cfcs (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 5/15