5900-152 Laboratory Certification Report

OMB Control Number: 2060-0170
Expiration Date: 4/16/2023

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).
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0170). Responses to
this collection of information are mandatory (40 CFR 82.13). 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 be 2.1 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 # 5900-152, Revised 10/19

OMB Control Number: 2060-0170
Expiration Date: 4/16/2023

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)