5900-152 Lab Use Certification

OMB Control Number: 2060-0170
Expiration Date: 8/31/21

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

LABORATORY CERTIFICATION REPORT (Sec

STRATOSPHERIC OZONE PROTECTION PROGRAM

SECTION 1

82.13)

LABORATORY IDENTIFICATION

1.1 Date of Submission

1.2

1.3 Number of Class I Substances
Reported

1.4 Number of Pages
Submitted

Original Submittal

Re-submittal

1.5 Laboratory Information
Laboratory Name
Street Address

City

State

Zip Code

Phone Number

Fax Number

1.6 Laboratory Contact Identification
Reporting Laboratory Contact Person

E-mail Address

1.7 Signature of Reporting Laboratory Representative
I certify that the quantities of controlled substances listed in this form are purchased solely for use in laboratory applications and will not be
resold or used in manufacturing.
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

SEND COMPLETED FORMS TO:

Date

The Company from Whom the
Class I Substances Were Purchased

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 2.1 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 # 5900-152, Revised 10/19

OMB Control Number: 2060-0170
Expiration Date: 8/31/21

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

LABORATORY CERTIFICATION REPORT (Sec

STRATOSPHERIC OZONE PROTECTION PROGRAM

SUBSTANCE IDENTIFICATION AND USE

SECTION 2

(Reproduce Additional Sheets as Needed)

2.1 Lab Name
2.2 Class I Substance (Select only one below)
CFC-11

CFC-12

CFC-13

CFC-113

CFC-114

CFC-115

CFC-111

CFC-112

Other CFC (please specify)

HBFC (please specify)

Halon (please specify)

Carbon Tetrachloride

Methyl Chloroform

CBM

Methyl Bromide

2.3 Amount of Class I Substance (kg)
2.4 Laboratory Applications (Select as many as apply and indicate percent use)
A. Research and Development
Reaction Solvent or Reaction Feedstock.......................................................

B. Analytical Uses and Regulated Applications
Reference
Chemical.............................................................................................
Toxicant...............................................................................................
Product................................................................................................

Extraction
Pesticide and Heavy Metal Detection................................................. G
____%
Product................................................................................................
Color & Food Additive Detection.........................................................
Diluent
Zinc, Copper, Cadmium Detection in Plants and Food.......................
Microchemical Methods to Determine Molecular Weight of Oxygen...
Measuring Drug Purity and Residual Information................................
Sterilization of Lab Equipment............................................................
Carrier (Inert)
Forensic Methods................................................................................
Titration...............................................................................................
Analytical Equipment...........................................................................

Tracer
Sanitary Engineering...........................................................................

Miscellaneous (Including Testing)
Ingredient in Material for Testing........................................................
Separation Media................................................................................

C. Miscellaneous
Laboratory Method Development.............................................
Sample Preparation Using Solvent...........................................

SECTION 3

SUPPLIER IDENTIFICATION

3.1 Supplier Name

EPA Form # 5900-152, Revised 10/19

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82.13)