5900-149 Class I Exporter Annual Report

---

Overview

Instructions
Section 1
Section 2
Summary
Reference List

---

Sheet 1: Instructions

	U.S. Environmental Protection Agency
	Stratospheric Ozone Protection Program
	Class I Exporter Annual Report (Sec 82.13)
	Version 1.0
	Last Updated: April 2018
	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 on 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 #5900-149
	OMB Control Number: 2060-0170
	Expiration Date: 10/31/2018

---

Sheet 2: Section 1

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

---

Sheet 3: Section 2

U.S. Environmental Protection Agency

Class I Exporter Annual Report

Company Name:

Reporting Period:

Section 2: Export Transaction Data

In the table below, enter data for each export transaction containing a class I controlled substance that took place during the reporting period. If no class I 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.

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 copying and pasting data into the table, please refer to the Reference List for the valid list of chemical names. Name of the Class I Chemical Exported

Enter the total quantity (kg) of the chemical exported. Quantity of the Class I 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 I chemicals. Commodity Code

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 Q must be selected prior to completing this field. - If the material is New, the intended use can be Global Lab, Other Essential Use (EU), Transformation, or Destruction. - If the material is Used, the intended use can be Transformation, Destruction, Aircraft Halon Bottles, 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

Autopopulated

Date

Text

Text

Text

Selection

Text

Text

Text

Selection

kg

Text

Text

Number

Selection

Selection

1

1/15/2018

Company A

1 Main Street

Melbourne

Australia

3000

John Smith

011 46 8 508 280 00

CFC-13

1,000.00

2903.77.0020

Miami, FL

12345678900

New

Global Lab

1st

1

x

x

x

x

Afghanistan

CBM

New

Global Lab

Albania

CCL4

Used

Other EU

Algeria

CFC-11

Transformation

Andorra

CFC-12

Destruction

Angola

CFC-13

Aircraft Halon Bottles

Antigua and Barbuda

CFC-111

Other

Argentina

CFC-112

Armenia

CFC-113

Australia

CFC-114

Austria

CFC-115

Azerbaijan

CFC-211

Bahamas

CFC-212

Bahrain

CFC-213

Bangladesh

CFC-214

Barbados

CFC-215

Belarus

CFC-216

Belgium

CFC-217

Belize

CH3CCL3

Benin

Halon 1202

Bermuda

Halon 1211

Bhutan

Halon 1301

Bolivia (Plurinational State of)

Halon 2402

Bosnia and Herzegovina

HBFCs

Botswana

Brazil

Brunei Darussalam

British Virgin Islands

Bulgaria

Burkina Faso

Burundi

Cambodia

Cameroon

Canada

Cape Verde

Central African Republic

Chad

Chile

China

Colombia

Comoros

Congo

Cook Islands

Costa Rica

Côte d'Ivoire

Croatia

Cuba

Cyprus

Czech Republic

Democratic Republic of the Congo

Denmark

Djibouti

Dominica

Dominican Republic

Ecuador

Egypt

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

European Union

Fiji

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

---

Sheet 4: Summary

									0
		U.S. Environmental Protection Agency
		Class I Exporter Annual 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)

---

Sheet 5: Reference List

	U.S. Environmental Protection Agency
	Class I Exporter Annual 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 I Chemicals					Source Country
	CFC-11	CFC-114	CFC-215	Halon 2402		Afghanistan	Greece	Papua New Guinea
	CFC-12	CFC-115	CFC-216	CBM		Albania	Grenada	Paraguay
	CFC-13	CFC-211	CFC-217	CCL4		Algeria	Guatemala	Peru
	CFC-111	CFC-212	Halon 1202	CH3CCL3		Andorra	Guinea	Philippines
	CFC-112	CFC-213	Halon 1211	HBFCs		Angola	Guinea-Bissau	Poland
	CFC-113	CFC-214	Halon 1301			Antigua and Barbuda	Guyana	Portugal
						Argentina	Haiti	Qatar
	Transaction Type List: The table below lists the valid transaction types that may be used when entering data into Section 2 of this form.					Armenia	Holy See	Republic of Moldova
						Australia	Honduras	Romania
						Austria	Hong Kong	Russian Federation
	Transaction Type					Azerbaijan	Hungary	Rwanda
	New	Used				Bahamas	Iceland	Saint Kitts and Nevis
						Bahrain	India	Saint Lucia
	Intended Use Lists: The tables below list the valid intended uses that may be used when entering data into Section 2 of this form.					Bangladesh	Indonesia	Saint Vincent and the Grenadines
						Barbados	Iran (Islamic Republic of)	Samoa
						Belarus	Iraq	San Marino
	Intended Uses - If Transaction Type = New					Belgium	Ireland	Sao Tome and Principe
	Global Lab	In-house Trans				Belize	Israel	Saudi Arabia
	Other EU	In-house Dest				Benin	Italy	Senegal
						Bermuda	Jamaica	Serbia
	Intended Uses - If Transaction Type = Used					Bhutan	Japan	Seychelles
	Transformation	Destruction	Aircraft Halon Bottles	Other		Bolivia (Plurinational State of)	Jordan	Sierra Leone
						Bosnia and Herzegovina	Kazakhstan	Singapore
	Commodity Code List: The table below lists the commonly used class I 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.					Botswana	Kenya	Slovakia
						Brazil	Kiribati	Slovenia
						Brunei Darussalam	Kuwait	Solomon Islands
						British Virgin Islands	Kyrgyzstan	Somalia (Federal Republic of)
	Class I Commodity Codes/Description					Bulgaria	Lao People's Democratic Republic	South Africa
	2903.77.0010	Trichlorofluoromethane (CFC-11)				Burkina Faso	Latvia	South Korea (Republic of Korea)
	2903.77.0020	Trichlorotrifluoroethanes (CFC-113)				Burundi	Lebanon	South Sudan
	2903.77.0030	Dichlorotetrafluoroethane (CFC-114)				Cambodia	Lesotho	Spain
	2903.77.0040	Monochloropentafluoroethane (CFC-115)				Cameroon	Liberia	Sri Lanka
	2903.77.0050	Dichlorodifluoromethane (CFC-12)				Canada	Libya	Sudan
	2903.77.0080	Other CFCs				Cape Verde	Liechtenstein	Suriname
	2903.14.0000	Carbon tetrachloride				Central African Republic	Lithuania	Swaziland
	2903.76.0010	Bromotrifluoromethane (Halon 1301)				Chad	Luxembourg	Sweden
	2903.76.0050	Bromochlorodifluoromethane (Halon 1211) and dibromotetrafluoroethanes (Halon 2402)				Chile	Madagascar	Switzerland
						China	Malawi	Syrian Arab Republic
	2903.79.1000	Bromochloromethane (CBM)				Colombia	Malaysia	Tahiti
	2903.19.6010	Methylchloroform (1,1,1-Trichloroethane)				Comoros	Maldives	Taiwan
	3824.71.0100	Mixtures containing chlorofluorocarbons (CFCs)				Congo	Mali	Tajikistan
	3824.72.0000	Mixtures containing bromochlorodifluoromethane (Halon 1211), bromotrifluoromethane (Halon 1301), or dibromotetrafluoroethanes (Halon 2402)				Cook Islands	Malta	Thailand
						Costa Rica	Marshall Islands	The Former Yugoslav Republic of Macedonia
						Côte d'Ivoire	Mauritania
	3824.73.0000	Mixtures containing hydrobromofluorocarbons (HBFCs)				Croatia	Mauritius	Timor-Leste
	3824.75.0000	Mixtures containing carbon tetrachloride				Cuba	Mexico	Togo
	3824.76.0000	Mixtures containing 1,1,1-trichloroethane (methyl chloroform)				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