Form 5900-200 CLASS II CONTROLLED SUBSTANCE IMPORTER QUARTERLY REPORT

OMB Control Number: 2060-0498

Expiration Date: TBD

U.S. Environmental Protection Agency stratospheric ozone protection program

class ii controlled substance importer quarterly report (Sec 82.24)

SECTION 1 IMPORTING COMPANY IDENTIFICATION

1.1 Date of Submission

     

1.2 Number of Transactions Reported

     

1.3 Number of Pages Submitted

     

1.4 Original Submittal Re-submittal

1.5 Quarter and Year to Which This Report Applies (Annual Reporting on heels required in the 4th quarter only)

1st

2nd

3rd

4th

Year           

1.6 Importing Company

Company Name      

Street Address      

City      

State      

Zip Code      

Nine-digit IRS Importer Number      

1.7 Company Contact Identification

Reporting Company Contact Person      

E-mail Address      

Phone Number      

Fax Number      

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: Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenue, NW Washington, DC 20460

For Private Courier: 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 4.5 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 # 5900-200, Revised 10/12

OMB Control Number: 2060-0498

Expiration Date: TBD

U.S. Environmental Protection Agency stratospheric ozone protection program

class ii controlled substance importer quarterly report (Sec 82.24)

SECTION 2 TRANSACTION RECORDS (Reproduce Additional Sheets as Needed)

2.1 Company Name

     

2.2 Transaction Summaries

TRANSACTION #

     

Source Country      

Customs Entry Summary Number      

Port of Entry into the U.S.      

Date of Import (mm/dd/yy)      

If Import Is Not a Blend:

HCFC:      

Quantity (kg):      

If Import Is a Blend:

Name of Blend:      

Quantity (kg):      

HCFC in Blend:       Quantity (kg):      

HCFC in Blend:       Quantity (kg):      

HCFC in Blend:       Quantity (kg):      

Transaction Type:

New

Used; Date of Non-objection Notice:      

Heels (Report Annual Imports in 4th Quarter Only)

If New:

HCFC-141b Exemption

Transformation

Destruction

None

If Used:

Transformation

Destruction

Other; Please Specify      

If Heels:

Included in Future Shipment

Transformation

Destruction

Non-Emissive Use

TRANSACTION #

     

Source Country      

Customs Entry Summary Number      

Port of Entry into the U.S.      

Date of Import (mm/dd/yy)      

If Import Is Not a Blend:

HCFC:      

Quantity (kg):      

If Import Is a Blend:

Name of Blend:      

Quantity (kg):      

HCFC in Blend:       Quantity (kg):      

HCFC in Blend:       Quantity (kg):      

HCFC in Blend:       Quantity (kg):      

Transaction Type:

New

Used; Date of Non-objection Notice:      

Heels (Report Annual Imports in 4th Quarter Only)

If New:

HCFC-141b Exemption

Transformation

Destruction

None Apply

If Used:

Transformation

Destruction

Other; Please Specify      

If Heels:

Included in Future Shipment

Transformation

Destruction

Non-Emissive Use

EPA Form # 5900-200, Revised 10/12

OMB Control Number: 2060-0498

Expiration Date: TBD

U.S. Environmental Protection Agency stratospheric ozone protection program

class ii controlled substance importer quarterly report (Sec 82.24)

SECTION 3 COMPANY IMPORT DATA

3.1 Company Name

     

3.2 Company Import Totals

A

B

C

D

E

F

G

H

I

J

Chemical Name (Commodity Code)

Gross Imports (kg)

In-House Transformation (kg)

Second-Party Transformation (kg)

In-House Destruction (kg)

Second-Party Destruction (kg)

HCFC-141b Exemption (kg)

Net Imports (B-C-D-E-F-G=H) (kg)

Total “Used” Imports (kg)

Total “Heels” (4th Quarter Reporting Only) (kg)

HCFC-22 (2903.71.0000)

     

     

     

     

     

     

     

     

     

HCFC-123 (2903.72.0020)

     

     

     

     

     

     

     

     

     

HCFC-124 (2903.79.9030)

     

     

     

     

     

     

     

     

     

HCFC-141b (2903.73.0000)

     

     

     

     

     

     

     

     

     

HCFC-142b (2903.74.0000)

     

     

     

     

     

     

     

     

     

HCFC-225ca (2903.75.0000)

     

     

     

     

     

     

     

     

     

HCFC-225cb (2903.75.0000)

     

     

     

     

     

     

     

     

     

HCFC and Commodity Code (if not listed above)      

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

EPA Form # 5900-200, Revised 10/12

OMB Control Number: 2060-0498

Expiration Date: TBD

U.S. Environmental Protection Agency stratospheric ozone protection program				class ii controlled substance importer quarterly report (Sec 82.24)
SECTION 4 ALLOWANCE EXPENDITURE TOTALS
4.1 Company Name	     
4.2 Allowance Balance Summary
A		B
Chemical Name		Total consumption allowances for year to date (as of the end of the quarter) that were:
		Expended			Unexpended
HCFC-22		     			     
HCFC-142b		     			     
HCFC-123		     			     
HCFC-124		     			     
HCFC-225ca		     			     
HCFC-225cb		     			     
4.3 Name(s) of HCFC-141b Exemption Allowance Holder(s) from whom Orders were Received and Associated Quantity (kg) of HCFC-141b Requested and Imported
Company Name:      			HCFC-141b Requested and Imported (kg):      
Company Name:      			HCFC-141b Requested and Imported (kg):      
Company Name:      			HCFC-141b Requested and Imported (kg):      
Company Name:      			HCFC-141b Requested and Imported (kg):      
Company Name:      			HCFC-141b Requested and Imported (kg):      

EPA Form # 5900-200, Revised 10/12