Form 5900-404 Reclamation Report

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Overview

Section 1
Section 2

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Sheet 1: Section 1

	U.S. Environmental Protection Agency		OMB Control Number: 2060-0256
	Stratospheric Protection Division		Expiration Date: MM/DD/YYYY
	Reclamation Annual Report (Sec 82.166)
	Instructions
	Complete this form by filling in the data fields that are highlighted in blue. Use the arrows to navigate between the tabs.
	To submit, please send your completed report to: [email protected].
	Section 1: Report Identification Information
	Date of Submission:
	Reporting Year:
	Company Name:
	Street Address:
	City:
	State:
	ZIP code:
	Contact Person Name:
	Email Address:
	Phone Number:
	Fax Number:
	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.
	An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The number and expiration date are displayed in the upper right corner of the form. The public reporting and recordkeeping burden for this collection of information is estimated to average 2 hours per year. 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 #5900-404

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Sheet 2: Section 2

		U.S. Environmental Protection Agency
		Stratospheric Protection Division
		Reclamation Annual Report (Sec 82.166)
		Company Name:
		Reporting Year:
		Section 2: Reclamation Data
		Mass of Waste Products (kg)
		Name of the Refrigerant Reclaimed	Mass of Material Received (kg)	Mass of Refrigerant Reclaimed (kg)
		TOTAL	0.00	0.00
		If "Other" is selected in the table above, please specify the refrigerant type below: