5900-504 Application for Set Aside of HFC Allowances

U.S. Environmental Protection Agency Allowance Allocation and Trading Program under the AIM Act

OMB Control Number: XXXX-XXXX Expiration Date: MM/DD/YYYY

Instructions

Complete this form by responding to each question below. Provide supporting documentation, as needed, to respond to the questions. Once completed, submit the report along with any attachments to EPA through the Central Data Exchange (CDX). Refer to EPA’s website for additional information on form submission: https://www.epa.gov/climate-hfcs-reduction/collection-data-support-establishment-hfc-allowance-allocation-and-trading

Application for Set Aside of HFC Allowances (Sec. 84.15)

Submitter Information

Company Name	Click or tap here to enter text.
Address	Click or tap here to enter text.
Contact Name	Click or tap here to enter text.
Email	Click or tap here to enter text.
Phone	Click or tap here to enter text.
Submission Date	Click or tap here to enter text.

1. Describe the complete ownership of the company, including percentages of ownership, and whether there is any familial relationship, if any, to owners of any other company producing, importing, or exporting HFCs (§84.15(d)(1)): Click or tap here to enter text.

2. Identify whether the company is a woman or minority owned business (§84.15(d)(2)): Click or tap here to enter text.

3. Provide the contact information for the owner of the company (§84.15(d)(3)): Click or tap here to enter text.

4. Provide the date of incorporation and the state in which the company is incorporated (§84.15(d)(4)): Click or tap here to enter text.

5. Provide the state license identifier (§84.15(d)(5)): Click or tap here to enter text.

6. Describe the company’s plan for importing HFCs (§84.15(d)(6)): Click or tap here to enter text.

7. Identify the prospective foreign exporter that the company anticipates working with (§84.15(d)(8)): Click or tap here to enter text.

8. Provide documentation demonstrating that the applicant meets conditions for a small business concern, as defined in 13 CFR part 121 (§84.15(d)(9)).

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. XXXX-XXXX). Responses to this collection of information are mandatory (40 CFR 84.31). 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 public reporting and recordkeeping burden for this collection of information is estimated to be X hours per response. Send comments on the Agency’s need this formation, 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, Regulatory Support Division, U.S. Environmental Protection Agency (2821T), 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 # 5900-504