5900-199 Class II Exporter Quarterly Report

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Overview

Instructions
Section 1
Section 2
Summary
Blend Breakout
Reference List

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Sheet 1: Instructions

	U.S. Environmental Protection Agency
	Stratospheric Ozone Protection Program
	Class II Exporter Quarterly Report (Sec 82.24)
	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 #5900-199
	OMB Control Number: 2060-0498
	Expiration Date: 4/30/2019

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Sheet 2: Section 1

	U.S. Environmental Protection Agency
	Class II Exporter 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
	Enter your company's Employer Identification Number (EIN). Employer Identification Number (EIN):			1
		Original Submission
		Re-Submittal

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Sheet 3: Section 2

U.S. Environmental Protection Agency

Class II Exporter Quarterly Report

Company Name:

Reporting Period:

Section 2: Export Transaction Data

In the table below, enter data for each export transaction containing a class II controlled substance that took place during the reporting period. If no controlled substances were exported, the table may be left blank. For all controlled substances that are exported, all fields are required.

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

If blends were exported, refer to the table of HCFC blends provided in the Blend Breakout tab, as needed.

The transaction number is autopopulated. Transaction Number

Enter the date for when the shipment exited the United States. Date of Export

Enter the name of the company that received or purchased material during the reporting period. Recipient Company

Enter the street address of the recipient company. Recipient Company Street Address

Enter the city of the recipient company. Recipient Company City

Select the country to which the shipment was exported. If copying and pasting data into the table, please refer to the Reference List for the valid list of countries. Recipient Company Country

Enter the postal code of the recipient company. Recipient Company Postal Code

Enter the name of the contact for the recipient company. If this information is not available, enter "Not Available." Recipient Company Contact Name

Enter the phone number of the contact from the recipient company. If this information is not available, enter "Not Available." Recipient Company Phone Number

Select the name of the chemical exported. If the chemical is a blend, select the name of the blend. A table of HCFC blends is provided in the 'Blends Breakout' tab for reference. If the export is a blend and the name of the blend is not listed in the dropdown list, select 'Other' and manually enter the name and quantity of each Class II chemical contained within the blend in columns O-T. If copying and pasting data into the table, please refer to the Reference List for the valid list of chemical names. Name of the Chemical Exported

Enter the total quantity (kg) of the chemical exported. If the chemical is a blend, the quantity should equal the total quantity of the blend. Quantity of the Chemical Exported

Enter the 10-digit commodity code of the chemical exported as it appears on Customs documentation. Refer to the Reference List for a list of commonly used commodity codes for class II chemicals. Commodity Code

These fields will automatically populate unless the name of the chemical imported is identified as 'Other'. Summary of Class II Controlled Substances Exported

Enter the name of the port where the shipment exited the United States. Port of Exit from the United States

Enter the Employer Identification Number (EIN) shown on the Shipper's Export Declaration Form. This number may or may not refer to the exporter as defined by EPA. If a shipping agent is acting on behalf of the exporter as defined by the regulation, the EIN of the agent shown on the U.S. Customs Form 7525 should be reported here. Your company's EIN as entered in Section 1 of this report will automatically populate for each transaction entered. Revise the number if the EIN for the shipment is different from your company's EIN. The number entered should have no dashes. Shipment EIN

Select the transaction type of the material. The transaction type can be New or Used. If copying and pasting data into the table, please refer to the Reference List for the valid list of transaction types. Transaction Type

Select the intended use of the material. Note that the Transaction Type in Column W must be selected prior to completing this field. - If the material is New, the intended use can be Produced/Imported for Consumption, Produced with Article 5 Allowances, Transformation, or Destruction. - If the material is Used, the intended use can be Transformation, Destruction, or Other. If copying and pasting data into the table, please refer to the Reference List for the valid list of intended uses. Intended Use

If the chemical exported is identified as 'Other', enter the name of the class II chemical exported as part of the blend or mixture. Please refer to the Reference List for the valid list of chemical names. Class II Chemical

If the chemical exported is identified as 'Other', enter the quantity of the class II chemical exported as part of the blend or mixture. Quantity Exported (kg)

If the chemical exported is identified as 'Other' and the mixture or blend contains more than one class II chemical, enter the name of the second class II chemical exported as part of the blend or mixture. Please refer to the Reference List for the valid list of chemical names. Class II Chemical

If the chemical exported is identified as 'Other' and the mixture or blend contains more than one class II chemical, enter the quantity of the second class II chemical exported as part of the blend or mixture. Quantity Exported (kg)

If the chemical exported is identified as 'Other' and the mixture or blend contains more than two class II chemicals, enter the name of the third class II chemical exported as part of the blend or mixture. Please refer to the Reference List for the valid list of chemical names. Class II Chemical

If the chemical exported is identified as 'Other' and the mixture or blend contains more than two class II chemicals, enter the quantity of the third class II chemical exported as part of the blend or mixture. Quantity Exported (kg)

Autopopulated

Date

Text

Text

Text

Selection

Text

Text

Text

Selection

kg

Text

Autopopulated

Autopopulated

Autopopulated

Autopopulated

Autopopulated

Autopopulated

Text

Number

Selection

Selection

1

1/15/2018

Company A

1 Main Street

Melbourne

Australia

3000

John Smith

011 46 8 508 280 00

HCFC-22

100.00

2903.71.0000

HCFC-22

100.00

Miami, FL

12345678900

New

Produced/Exported for Consumption

1

x

x

x

x

Afghanistan

HCFC-21

New

Transformation

Albania

HCFC-22

Used

Destruction

Algeria

HCFC-31

Produced/Exported for Consumption

Andorra

HCFC-121

Produced with Article 5 Allowances

Angola

HCFC-122

Other

Antigua and Barbuda

HCFC-123

Argentina

HCFC-123a

Armenia

HCFC-123b

Australia

HCFC-124

Austria

HCFC-124a

Azerbaijan

HCFC-131

Bahamas

HCFC-132b

Bahrain

HCFC-133a

Bangladesh

HCFC-141b

Barbados

HCFC-142b

Belarus

HCFC-151

Belgium

HCFC-221

Belize

HCFC-222

Benin

HCFC-223

Bermuda

HCFC-224

Bhutan

HCFC-225ca

Bolivia (Plurinational State of)

HCFC-225cb

Bosnia and Herzegovina

HCFC-226

Botswana

HCFC-231

Brazil

HCFC-232

Brunei Darussalam

HCFC-233

British Virgin Islands

HCFC-234

Bulgaria

HCFC-235

Burkina Faso

HCFC-241

Burundi

HCFC-242

Cambodia

HCFC-243

Cameroon

HCFC-244

Canada

HCFC-251

Cape Verde

HCFC-252

Central African Republic

HCFC-253

Chad

HCFC-261

Chile

HCFC-262

China

HCFC-271

Colombia

R-401A

Comoros

R-401B

Congo

R-401C

Cook Islands

R-402A

Costa Rica

R-402B

Côte d'Ivoire

R-403A

Croatia

R-403B

Cuba

R-405A

Cyprus

R-406A

Czech Republic

R-408A

Democratic Republic of the Congo

R-409A

Denmark

R-409B

Djibouti

R-411A

Dominica

R-411B

Dominican Republic

R-411C

Ecuador

R-412A

Egypt

R-414A

El Salvador

R-414B

Equatorial Guinea

R-415A

Eritrea

R-415B

Estonia

R-416A

Ethiopia

R-418A

European Union

R-420A

Fiji

Other

Finland

France

Gabon

Gambia

Georgia

Germany

Ghana

Greece

Grenada

Guatemala

Guinea

Guinea-Bissau

Guyana

Haiti

Holy See

Honduras

Hong Kong

Hungary

Iceland

India

Indonesia

Iran (Islamic Republic of)

Iraq

Ireland

Israel

Italy

Jamaica

Japan

Jordan

Kazakhstan

Kenya

Kiribati

Kuwait

Kyrgyzstan

Lao People's Democratic Republic

Latvia

Lebanon

Lesotho

Liberia

Libya

Liechtenstein

Lithuania

Luxembourg

Madagascar

Malawi

Malaysia

Maldives

Mali

Malta

Marshall Islands

Mauritania

Mauritius

Mexico

Micronesia (Federated States of)

Monaco

Mongolia

Montenegro

Morocco

Mozambique

Myanmar

Namibia

Nauru

Nepal

Netherlands

New Zealand

Nicaragua

Niger

Nigeria

Niue

North Korea (Democratic People's Republic of Korea)

Norway

Oman

Pakistan

Palau

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Poland

Portugal

Qatar

Republic of Moldova

Romania

Russian Federation

Rwanda

Saint Kitts and Nevis

Saint Lucia

Saint Vincent and the Grenadines

Samoa

San Marino

Sao Tome and Principe

Saudi Arabia

Senegal

Serbia

Seychelles

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

Somalia (Federal Republic of)

South Africa

South Korea (Republic of Korea)

South Sudan

Spain

Sri Lanka

Sudan

Suriname

Swaziland

Sweden

Switzerland

Syrian Arab Republic

Tahiti

Taiwan

Tajikistan

Thailand

The Former Yugoslav Republic of Macedonia

Timor-Leste

Togo

Tonga

Trinidad and Tobago

Tunisia

Turkey

Turkmenistan

Tuvalu

Uganda

Ukraine

United Arab Emirates

United Kingdom of Great Britain and Northern Ireland

United Republic of Tanzania

#NAME?

Uruguay

Uzbekistan

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Sheet 4: Summary

		U.S. Environmental Protection Agency
		Class II Exporter Quarterly Report
		Company Name:
		Reporting Period:
		Export Totals
		The values in the table below are calculated based on data entered in Section 2. If the totals appear to be incorrect, please return to Section 2 to review your data.
		Chemical Name	Country	Total Exported (kg)

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Sheet 5: Blend Breakout

	U.S. Environmental Protection Agency
	Class II Exporter Quarterly Report
	Blend Breakout Table
	Chemical Name	HCFC-22	HCFC-124	HCFC-142b
	R-401A	53%	34%
	R-401B	61%	28%
	R-401C	33%	52%
	R-402A	38%
	R-402B	60%
	R-403A	75%
	R-403B	56%
	R-405A	45%		5.5%
	R-406A	55%		41%
	R-408A	46%
	R-409A	60%	25%	15%
	R-409B	65%	25%	10%
	R-411A	87.5%
	R-411B	94%
	R-411C	95.5%
	R-412A	70%		25%
	R-414A	51%	28.5%	16.5%
	R-414B	50%	39%	9.5%
	R-415A	82%
	R-415B	25%
	R-416A		39%
	R-418A	96%
	R-420A			12%

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Sheet 6: Reference List

	U.S. Environmental Protection Agency
	Class II Exporter 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 lists provided below.
	Chemical Name List: The table below lists the valid chemical names that may be used when entering data into Section 2 of this form.					Country List: The table below lists the valid country names that may be used when entering data into Section 2 of this form.
	Class II Chemicals (including blends)					Source Country
	HCFC-21	HCFC-142	HCFC-241	R-405A		Afghanistan	Greece	Papua New Guinea
	HCFC-22	HCFC-142a	HCFC-242	R-408A		Albania	Grenada	Paraguay
	HCFC-31	HCFC-142b	HCFC-243	R-409A		Algeria	Guatemala	Peru
	HCFC-121	HCFC-151	HCFC-244	R-409B		Andorra	Guinea	Philippines
	HCFC-122	HCFC-221	HCFC-251	R-411A		Angola	Guinea-Bissau	Poland
	HCFC-123	HCFC-222	HCFC-252	R-411B		Antigua and Barbuda	Guyana	Portugal
	HCFC-123a	HCFC-223	HCFC-253	R-411C		Argentina	Haiti	Qatar
	HCFC-123b	HCFC-224	HCFC-261	R-412A		Armenia	Holy See	Republic of Moldova
	HCFC-124	HCFC-225ca	HCFC-262	R-414A		Australia	Honduras	Romania
	HCFC-124a	HCFC-225cb	HCFC-271	R-414B		Austria	Hong Kong	Russian Federation
	HCFC-131	HCFC-226	R-401A	R-415A		Azerbaijan	Hungary	Rwanda
	HCFC-132b	HCFC-231	R-401B	R-415B		Bahamas	Iceland	Saint Kitts and Nevis
	HCFC-133a	HCFC-232	R-401C	R-416A		Bahrain	India	Saint Lucia
	HCFC-141	HCFC-233	R-402A	R-418A		Bangladesh	Indonesia	Saint Vincent and the Grenadines
	HCFC-141a	HCFC-234	R-402B	R-420A		Barbados	Iran (Islamic Republic of)	Samoa
	HCFC-141b	HCFC-235	R-403A	Other		Belarus	Iraq	San Marino
						Belgium	Ireland	Sao Tome and Principe
	Transaction Type List: The table below lists the valid transaction types that may be used when entering data into Section 2 of this form.					Belize	Israel	Saudi Arabia
						Benin	Italy	Senegal
						Bermuda	Jamaica	Serbia
	Transaction Type					Bhutan	Japan	Seychelles
	New	Used				Bolivia (Plurinational State of)	Jordan	Sierra Leone
						Bosnia and Herzegovina	Kazakhstan	Singapore
	Intended Use Lists: The tables below list the valid intended uses that may be used when entering data into Section 2 of this form.					Botswana	Kenya	Slovakia
						Brazil	Kiribati	Slovenia
						Brunei Darussalam	Kuwait	Solomon Islands
	Intended Uses - If Transaction Type = New					British Virgin Islands	Kyrgyzstan	Somalia (Federal Republic of)
	Transformation	Produced/Imported for Consumption				Bulgaria	Lao People's Democratic Republic	South Africa
	Destruction	Produced with Article 5 Allowances				Burkina Faso	Latvia	South Korea (Republic of Korea)
						Burundi	Lebanon	South Sudan
	Intended Uses - If Transaction Type = Used					Cambodia	Lesotho	Spain
	Transformation	Destruction	Other			Cameroon	Liberia	Sri Lanka
						Canada	Libya	Sudan
	Commodity Code List: The table below lists the commonly used class II commodity codes that may be used when entering data into Section 2 of this form. A complete list of commodity codes can be found in the Official Harmonized Tariff Schedule.					Cape Verde	Liechtenstein	Suriname
						Central African Republic	Lithuania	Swaziland
						Chad	Luxembourg	Sweden
						Chile	Madagascar	Switzerland
	Class II Commodity Codes/Description					China	Malawi	Syrian Arab Republic
	2903.71.0000	Chlorodifluoromethane (HCFC-22)				Colombia	Malaysia	Tahiti
	2903.72.0020	Dichlorotrifluoroethane (HCFC-123)				Comoros	Maldives	Taiwan
	2903.72.0050	Other Dichlorotrifluoroethanes (HCFC-123a, HCFC-123b)				Congo	Mali	Tajikistan
	2903.73.0000	Dichlorofluoroethanes (HCFC-141b)				Cook Islands	Malta	Thailand
	2903.74.0000	Chlorodifluoroethanes (HCFC-142b)				Costa Rica	Marshall Islands	The Former Yugoslav Republic of Macedonia
	2903.75.0000	Dichloropentafluoropropanes (HCFC-225ca, HCFC-225cb)				Côte d'Ivoire	Mauritania
	2903.79.9030	Monochlorotetrafluoroethane (HCFC-124)				Croatia	Mauritius	Timor-Leste
	2903.79.9070	Other HCFCs				Cuba	Mexico	Togo
	3824.74.0000	Mixtures containing hydrochlorofluorocarbons (HCFCs) but not containing chlorofluorocarbons (CFCs)				Cyprus	Micronesia (Federated States of)	Tonga
						Czech Republic	Monaco	Trinidad and Tobago
						Democratic Republic of the Congo	Mongolia	Tunisia
						Denmark	Montenegro	Turkey
						Djibouti	Morocco	Turkmenistan
						Dominica	Mozambique	Tuvalu
						Dominican Republic	Myanmar	Uganda
						Ecuador	Namibia	Ukraine
						Egypt	Nauru	United Arab Emirates
						El Salvador	Nepal	United Kingdom of Great Britain and Northern Ireland
						Equatorial Guinea	Netherlands
						Eritrea	New Zealand	United Republic of Tanzania
						Estonia	Nicaragua	Uruguay
						Ethiopia	Niger	Uzbekistan
						European Union	Nigeria	Vanuatu
						Fiji	Niue	Venezuela (Bolivarian Republic of)
						Finland	North Korea (Democratic People's Republic of Korea)	Viet Nam
						France		Yemen
						Gabon	Norway	Zambia
						Gambia	Oman	Zimbabwe
						Georgia	Pakistan
						Germany	Palau
						Ghana	Panama