5900-153 Class I Lab Supplier Quarterly Report

---

Overview

Instructions
Section 1
Section 2
Section 3
Summary
Reference List

---

Sheet 1: Instructions

	U.S. Environmental Protection Agency
	Stratospheric Ozone Protection Program
	Class I Lab Supplier Quarterly Report (Sec 82.13)
	Version 1.0
	Last Updated: December 2017
	Instructions
	Complete this form by filling in the data fields that are highlighted in blue. Guidance on how to complete individual data fields are provided in comment bubbles. Use the arrows to navigate between the tabs. Once completed, use the 'prepare submission' button in the Summary tab to generate your CSV file.
	Copying and Pasting Data: If data are pasted into this reporting form from another spreadsheet, the formatting of specific cells must be consistent with the requirements of the form in order to be
	accepted into EPA’s ODS Tracking System. Refer to the Reference List to identify the valid naming scheme for specific data fields. Additionally, select "Paste As Values" when pasting data into the form.
	Report Submission: This Excel file, the generated CSV file, and all supporting attachments should be submitted to EPA through the Central Data Exchange (CDX). Refer to EPA's website for additional information on form submission:
	https://www.epa.gov/ods-phaseout/ods-recordkeeping-and-reporting
	All information submitted to EPA will be treated as confidential in accordance with 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart.
	The public reporting and recordkeeping burden for this collection of information is estimated to average 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 Avenue NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
	EPA Form #5900-153
	OMB Control Number: 2060-0170
	Expiration Date: 10/31/2018

---

Sheet 2: Section 1

	U.S. Environmental Protection Agency
	Class I Lab Supplier Quarterly Report
	Date Prepared:
	Section 1: Report Identification Information
	Complete all fields below. No fields may be left blank.
	The company name must match the organization name under which this report is submitted to EPA through CDX. Company Name:			1
	Submission Type:			1
	Reporting Year:			1
	Reporting Quarter:			1
		x
		Original Submission
		Re-Submittal

---

Sheet 3: Section 2

U.S. Environmental Protection Agency

Class I Lab Supplier Quarterly Report

Company Name:

Reporting Period:

Section 2: Amounts Purchased/Received

In the table below, enter data for each transaction in which a class I controlled substance was purchased or received under the global essential laboratory and analytical use exemption from a producer, importer, and/or distributor during the reporting period. If no controlled substances were purchased or received under the global essential laboratory and analytical use exemption during the reporting period, the table may be left blank. For each transaction, all fields are required.

If copying and pasting data into the table, please refer to the Reference List and the accompanying instructions.

The transaction number is autopopulated. Transaction Number

Enter the name of the company from which the material was received or purchased during the reporting period. Source Company

Enter the street address of the source company. Source Company Street Address

Enter the city of the source company. Source Company City

Select the state of the source company. If copying and pasting data into the table, please refer to the Reference List for the valid list of states. Source Company State

Enter the postal code of the source company. Source Company Postal Code

Select the name of the class I chemical purchased or received from the producer, importer, or distributor. If copying and pasting data into the table, please refer to the Reference List for the valid list of chemical names. Name of Class I Chemical Purchased or Received

Enter the total quantity (kg) of the chemical purchased or received from the producer, importer, or distributor. Quantity of Class I Chemical Purchased or Received

Autopopulated

Text

Text

Text

Selection

Text

Selection

kg

1

Company A

1 Main Street

Washington

District of Columbia

20006

CFC-13

5,000.00

1st

x

x

Alaska

CBM

Alabama

CCL4

Arkansas

CFC-11

Arizona

CFC-12

California

CFC-13

Colorado

CFC-111

Connecticut

CFC-112

District of Columbia

CFC-113

Delaware

CFC-114

Florida

CFC-115

Georgia

CFC-211

Hawaii

CFC-212

Iowa

CFC-213

Idaho

CFC-214

Illinois

CFC-215

Indiana

CFC-216

Kansas

CFC-217

Kentucky

CH3Br

Louisiana

CH3CCL3

Massachusetts

Halon 1202

Maryland

Halon 1211

Maine

Halon 1301

Michigan

Halon 2402

Minnesota

HBFCs

Missouri

Mississippi

Montana

North Carolina

North Dakota

Nebraska

New Hampshire

New Jersey

New Mexico

Nevada

New York

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Virginia

US Virgin Islands

Vermont

Washington

Wisconsin

West Virginia

Wyoming

---

Sheet 4: Section 3

U.S. Environmental Protection Agency

Class I Lab Supplier Quarterly Report

Company Name:

Reporting Period:

Section 3: Amounts Supplied to Laboratories

In the table below, identify the name and quantity of each class I controlled substance supplied to a laboratory customer during the reporting period. Up to three chemicals may be entered per row. You may enter more than one row of data per laboratory customer, as needed. If no controlled substances were supplied to laboratory customers under the global essential laboratory and analytical use exemption during the reporting period, the table may be left blank.

If copying and pasting data into the table, please refer to the Reference List and the accompanying instructions.

This field is autopopulated. Transaction Number

Enter the name of the laboratory company to which the material was supplied during the reporting period. Lab Company Name

Enter the street address of the laboratory company. Lab Company Street Address

Enter the city of the laboratory company. Lab Company City

Select the state in which the laboratory company is located. If copying and pasting data into the table, please refer to the Reference List for the valid list of states. Lab Company State

Enter the postal code of the laboratory company. Lab Company Postal Code

Class I Chemical Supplied to Lab

Class I Chemical Supplied to Lab

Class I Chemical Supplied to Lab

Select the name of the chemical supplied to the laboratory company. If copying and pasting data into the table, please refer to the Reference List for the valid list of chemical names. Name

Enter the total quantity (kg) of the chemical supplied to the laboratory company. Note that if the quantity is less than 0.00049 and appears in the cell as 0.000, it will still be accurately captured by the form. Quantity

Select the name of the chemical supplied to the laboratory company. If copying and pasting data into the table, please refer to the Reference List for the valid list of chemical names. Name

Enter the total quantity (kg) of the chemical supplied to the laboratory company. Note that if the quantity is less than 0.00049 and appears in the cell as 0.000, it will still be accurately captured by the form. Quantity

Select the name of the chemical supplied to the laboratory company. If copying and pasting data into the table, please refer to the Reference List for the valid list of chemical names. Name

Enter the total quantity (kg) of the chemical supplied to the laboratory company. Note that if the quantity is less than 0.00049 and appears in the cell as 0.000, it will still be accurately captured by the form. Quantity

Autopopulated

Text

Text

Text

Selection

Text

Selection

kg

Selection

kg

Selection

kg

1

Company A

1 Main Street

Washington

District of Columbia

20006

CFC-11

2.567

CFC-113

0.006

x

x

x

x

Alaska

CBM

CBM

CBM

Alabama

CCL4

CCL4

CCL4

Arkansas

CFC-11

CFC-11

CFC-11

Arizona

CFC-12

CFC-12

CFC-12

California

CFC-13

CFC-13

CFC-13

Colorado

CFC-111

CFC-111

CFC-111

Connecticut

CFC-112

CFC-112

CFC-112

District of Columbia

CFC-113

CFC-113

CFC-113

Delaware

CFC-114

CFC-114

CFC-114

Florida

CFC-115

CFC-115

CFC-115

Georgia

CFC-211

CFC-211

CFC-211

Hawaii

CFC-212

CFC-212

CFC-212

Iowa

CFC-213

CFC-213

CFC-213

Idaho

CFC-214

CFC-214

CFC-214

Illinois

CFC-215

CFC-215

CFC-215

Indiana

CFC-216

CFC-216

CFC-216

Kansas

CFC-217

CFC-217

CFC-217

Kentucky

CH3Br

CH3Br

CH3Br

Louisiana

CH3CCL3

CH3CCL3

CH3CCL3

Massachusetts

Halon 1202

Halon 1202

Halon 1202

Maryland

Halon 1211

Halon 1211

Halon 1211

Maine

Halon 1301

Halon 1301

Halon 1301

Michigan

Halon 2402

Halon 2402

Halon 2402

Minnesota

HBFCs

HBFCs

HBFCs

Missouri

Mississippi

Montana

North Carolina

North Dakota

Nebraska

New Hampshire

New Jersey

New Mexico

Nevada

New York

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Virginia

US Virgin Islands

Vermont

Washington

Wisconsin

West Virginia

Wyoming

---

Sheet 5: Summary

		U.S. Environmental Protection Agency
		Class I Lab Supplier Quarterly Report
		Company Name:
		Reporting Period:
		The values in the table below are calculated based on data entered in Section 2 and Section 3. If the totals appear to be incorrect, please return to Section 2 or Section 3 to review your data.
		Chemical Name	Total Quantity of Class I Chemical Purchased or Received (kg)	Total Quantity of Class I Chemical Supplied (kg)

---

Sheet 6: Reference List

	U.S. Environmental Protection Agency
	Class I Lab Supplier Quarterly Report
	Reference List
	Copying and Pasting Data: If data is pasted into this reporting form from another spreadsheet, the formatting of specific cells must be consistent with the requirements of the form in order to be accepted into EPA’s ODS tracking system. When copying and pasting data into the form, please ensure consistency with the formatting of the list below.
	Chemical Name List: The table below lists the valid chemical names that may be used when entering data into Section 2 and Section 3 of this form.
	Class I Chemicals
	CBM	CFC-111	CFC-211	CFC-216	Halon 1211
	CCL4	CFC-112	CFC-212	CFC-217	Halon 1301
	CFC-11	CFC-113	CFC-213	CH3Br	Halon 2402
	CFC-12	CFC-114	CFC-214	CH3CCL3	HBFCs
	CFC-13	CFC-115	CFC-215	Halon 1202
	State List: The table below lists the valid state names that may be used when entering data into Section 2 and Section 3 of this form.
	States
	Alaska	Hawaii	Michigan	Nevada	Texas
	Alabama	Iowa	Minnesota	New York	Utah
	Arkansas	Idaho	Missouri	Ohio	Virginia
	Arizona	Illinois	Mississippi	Oklahoma	US Virgin Islands
	California	Indiana	Montana	Oregon	Vermont
	Colorado	Kansas	North Carolina	Pennsylvania	Washington
	Connecticut	Kentucky	North Dakota	Puerto Rico	Wisconsin
	District of Columbia	Louisiana	Nebraska	Rhode Island	West Virginia
	Delaware	Massachusetts	New Hampshire	South Carolina	Wyoming
	Florida	Maryland	New Jersey	South Dakota
	Georgia	Maine	New Mexico	Tennessee