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OMB Control Number: 2060-XXXX |
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Expiration Date: X/XX/202X |
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| American Innovation and Manufacturing Act - Application for Set-aside of HFC Allowances |
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| Worksheet Instructions: |
| Use this workbook to provide EPA with information to be eligible for consideration for HFC allowances from the set-aside pool. Information must be provided by November 30, 2021. Submit this completed form along with any supporting documentation to EPA through the ODS Tracking System (ODSTS). Instructions on how to report data through the ODSTS are available at <https://www.epa.gov/ods-phaseout/submitting-other-documents-epa>. Select "HFC Set-Aside Application" as the document type when submitting your report. |
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| EPA has the authority to request additional information or ask follow up questions to verify the information and supporting documentation submitted as part of this application. |
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| Persons who qualify for set-aside allowances because they are application-specific end-users should complete Section 2 of this reporting form. |
| Persons who qualify for set-aside allowances because they are new importers should complete Section 3 of this reporting form. |
| Persons who qualify for set-aside allowances because they imported regulated substances in 2020 but were not required to report under 40 CFR part 98 and were not issued allowances as of October 1, 2021, must complete Section 1 of this form through ODSTS and provide EPA with the with the information detailed in §84.15(d)(1)(ii) and §84.15(d)(1)(iii) by November 30, 2021 through e-GGRT. Instructions on how to report data through e-GGRT and the required forms are available at <https://ccdsupport.com/confluence/display/help/e-GGRT+and+HFC+Data+Reporting+related+to+AIM>. |
| Version: |
| v0.2 |
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| Updated: |
| 9/28/2021 |
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| Reporting Form Navigation: |
| Section 1 - Company Identification |
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| Section 2a - Application-Specific Use Information |
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| Section 2b - Application-Specific Use Projections |
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| Section 2c - Contracting Information |
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| Section 3a - New Importer Information |
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| Section 3b - Plan for Importing HFCs |
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| Section 3c - Certifications |
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| Section 1 - Company Identification |
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| Instructions: Complete the following company information for the company that is applying for allowances under the HFC Allowance Set-aside. §84.15(d) |
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| Company Name |
Street Address |
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State/U.S. Territory |
Zip |
Country |
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| Instructions: Describe the complete ownership of the company, including percentages of ownership and the name of the parent company or owners. §84.15(d) |
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| Instructions: Provide the following information for the designated representative at the company. §84.15(d) |
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| Designated Representative |
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| Contact Name |
Contact Email |
Contact Phone |
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| Instructions: Select the reason your company is eligible for set-aside allowances. |
| Reason for Eligibility |
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| This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-XXXX). Responses to this collection of information are mandatory (40 CFR 84.15). 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 44 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. |
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| EPA Form # 5900-534 |
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OMB Control Number: 2060-XXXX |
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Expiration Date: X/XX/202X |
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| American Innovation and Manufacturing Act - Application for Set-aside of HFC Allowances |
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| Version: |
| v0.2 |
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| Updated: |
| 9/28/2021 |
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| Reporting Form Navigation: |
| Section 1 - Company Identification |
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| Section 2a - Application-Specific Use Information |
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| Section 2b - Application-Specific Use Projections |
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| Section 2c - Contracting Information |
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| Section 3a - New Importer Information |
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| Section 3b - Plan for Importing HFCs |
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| Section 3c - Certifications |
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| Section 2a - Application-Specific Use Information |
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| Instructions: Entities that qualify for application-specific allowances under § 84.13 that were not issued allowances as of October 1, 2021 must provide the information requested below. |
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| Instructions: Select from the dropdown menu the application your company uses. |
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| Instructions: Provide a description of the use of regulated substances and a detailed explanation of how the use is an application-specific use listed in §84.31(a). §84.31(h)(2)(i) |
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| Instructions: Provide the total quantity of all regulated substances acquired for application-specific use in the previous three years. Provide a copy of the sales records, invoices, or other records documenting that quantity. §84.31(h)(2)(ii) |
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| HFC |
Quantity Aquired in 2018 (kg) |
Quantity Aquired in 2019 (kg) |
Quantity Aquired in 2020 (kg) |
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| Instructions: Provide the name of the entity or entities supplying regulated substances for application-specific use and contact information for those suppliers. §84.31(h)(2)(iii) |
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| Supplier Information |
| Company Name |
Contact Name |
Contact Phone |
Contact Email |
City |
State/U.S. Territory |
Zip |
Country |
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| Instructions: Provide the quantities of regulated substances held in inventory for application-specific use as of June 30 of this year and the prior year. §84.31(h)(2)(iv) |
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| HFC Inventory |
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| HFC |
Quantity held in Inventory as of June 30, 2020 (kg) |
Quantity held in Inventory as of June 30, 2021 (kg) |
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| Instructions: Describe plans to transition to regulated substances with a lower exchange value or alternatives to regulated substances. §84.31(h)(2)(v) |
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| Section 2b - Application-Specific Use Projections |
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| Instructions: If requesting additional allowances due to one or more of the circumstances listed in § 84.13(b)(1), provide a projection of the monthly quantity of additional regulated substances needed by month in the next calendar year. §84.31(h)(2)(vi) |
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| Month |
Quantity of Projected Needs (kg) |
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| January 2022 |
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| February 2022 |
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| March 2022 |
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| April 2022 |
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| May 2022 |
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| June 2022 |
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| July 2022 |
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| August 2022 |
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| September 2022 |
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| October 2022 |
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| November 2022 |
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| December 2022 |
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| TOTAL |
0.00 |
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| Instructions: Provide a detailed explanation, including relevant supporting documentation (e.g., explanation of amounts of products that must be delivered under new contracts, copies of permits or other documentation to clarify when the new line or facility is opening, more recent sales numbers to document growth in MDI sales resulting from a public health emergency) to justify the additional need. §84.31(h)(2)(vi) |
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| Section 2c - Contracting Information |
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| Does your company contract out the manufacturing of defense sprays or metered dose inhalers, or contract out the servicing of onboard aerospace fire suppression? |
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| Instructions: If applicable, provide the contact information for a representative of the person(s) contracted to do the manufacturing or servicing. §84.31(h)(2)(vii) |
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| Manufacturing/Servicing Representative |
| Company Name |
Contact Name |
Contact Phone |
Contact Email |
City |
State/U.S. Territory |
Zip |
Country |
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| Instructions: Provide clarification on whether the responses provided in Sections 2a and 2b above apply to the company that is requesting application-specific allowances or the company receiving the contract for manufacturing and/or servicing using application-specific allowances. §84.31(h)(2)(vii) |
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OMB Control Number: 2060-XXXX |
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Expiration Date: X/XX/202X |
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| American Innovation and Manufacturing Act - Application for Set-aside of HFC Allowances |
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| Version: |
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| v0.2 |
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| Updated: |
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| 9/28/2021 |
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| Reporting Form Navigation: |
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| Section 1 - Company Identification |
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| Section 2a - Application-Specific Use Information |
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| Section 2b - Application-Specific Use Projections |
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| Section 2c - Contracting Information |
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| Section 3a - New Importer Information |
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| Section 3b - Plan for Importing HFCs |
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| Section 3c - Certifications |
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| Section 3a - New Importer Information |
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| Instructions: Persons who imported regulated substances in 2020 that were not required to report under 40 CFR part 98 and were not issued allowances as of October 1, 2021 must provide the information requested below. |
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| Owner of the Company §84.15(d)(2)(iii) |
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| Contact Name |
Contact Email |
Contact Phone |
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| Is the company a woman or minority owned businesss. §84.15(d)(2)(ii) |
Date of Incorporation §84.15(d)(2)(iv) |
State in which Company is Incorporated §84.15(d)(2)(iv) |
State License Identifier §84.15(d)(2)(v) |
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| Section 3b - Plan for Importing HFCs |
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| Instructions: Provide the following information detailing the company's plan for importing HFCs. §84.15(d)(2)(vi) |
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| Instructions: Describe what equipment and facilities the company has or needs to acquire to manage compressed gases. |
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| Does the company currently sell HFCs or other industrial gases? |
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| Does the company have any past experience importing HFCs? |
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| If you responded yes to either question above, describe your experience. |
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| Will the company be working with a customs broker? |
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If yes, which brokerage firm? |
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| Instructions: Indicate the month(s) in which the company intends to import HFCs. |
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| Month |
Intend to Import HFCs |
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| January |
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| February |
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| March |
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| April |
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| May |
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| June |
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| July |
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| Augus |
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| September |
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| October |
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| November |
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| December |
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| Instructions: Identify the single component HFC(s) the company intends to import and the CAS number for each. |
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| Intended HFC Imports |
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| HFC |
CAS Number |
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| Instructions: Identify the HFC blends the company intends to import and the ASHRAE numerical designation of the refrigerant or the percentage of the mixture containing each regulated substance and the CAS numbers for each neat HFC. |
| Intended HFC Blend Imports |
| HFC Blend |
HFC Component (1) |
HFC Component (2) |
HFC Component (3) |
| HFC |
HFC Composition of Blend (%) |
CAS Number |
HFC |
HFC Composition of Blend (%) |
CAS Number |
HFC |
HFC Composition of Blend (%) |
CAS Number |
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| Instructions: Identify the HTS codes for the HFCs and HFC blends the company intends to import. |
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| HTS Codes |
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| Instructions: Identify the prospective foreign exporter that the applicant anticipates working with and provide confirmation from the foreign exporter that the timeline for imports is accurate and achievable. §84.15(d)(2)(vii) |
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| Does your submission including supporting documentation from the foreign exporter confirming that the timeline for imports is accurate and achievable? |
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| Section 3c - Certifications |
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| Instructions: Provide a letter from a responsible official, defined as an individual designated by the company with the authority and responsibility to act on behalf of the company, certifying the following: |
Documentation Provided? |
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| The company intends to import HFCs in calendar years 2022 and 2023. |
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| Certification that I and/or my company do not share corporate or common ownership, corporate affiliation in the past five years, or familial relations with entities receiving allowances through the rule entitled, "Phasedown of Hydrofluorocarbons: Establishing the Allowance Allocation and Trading Program under the American Innovation and Manufacturing Act”. |
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| The company has read the HFC Allocation final rule, available by visiting <https://www.epa.gov/climate-hfcs-reduction/final-rule-phasedown-hydrofluorocarbons-establishing-allowance-allocation>, and understands the following sections of the new HFC Allocation regulation: |
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| 40 CFR 84.5 Prohibitions relating to regulated substances. |
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| 40 CFR 84.15 Set-aside of application-specific allowances, production allowances, and consumption allowances. |
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| 40 CFR 84.19 Transfers of allowances. |
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| 40 CFR 84.23 Certification identification generation and tracking. |
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| 40 CFR 84.31(a), (c), (h), and (k) Recordkeeping and reporting. |
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| 40 CFR 84.33 Auditing of recordkeeping and reporting. |
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| 40 CFR 84.35 Administrative consequences. |
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| The company will meet all applicable U.S. Department of Transportation (DOT) standards and all cylinders and containers used by the company will be compliant with the DOT standards found at CFR Title 49 part §178. |
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| The company will pay any duties conistent with U.S. Customs and Border Protection (CBP) requirements per Title 19. |
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| The company will comply with all EPA requirements, including those established under the AIM Act and annual Greenhouse Gas reporting requirements. §84.15(d)(2)(viii) |
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| The information submitted in this form is complete, accurate, and truthful. §84.15(d)(2)(ix) |
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