HFC Transformation One-Time Reporting Form

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American Innovation and Manufacturing Act - HFC Transformation One-Time Reporti
Worksheet Instructions:
Version:
r0.2
Updated:
9/21/2021
External Links:
Reporting Form Navigation:
Section 1 - Facility Identification
Section 2 - Transformation Process Information

Section 1 - Facility Identification
Instructions: Complete the following Facility information.
Company Name:
Facility Name:
AIMRS Facility ID:

Section 2 - Transformation Process Information

Instructions: Provide the following information on the transformation process performed at your facility. Provide supportin
respond to these reporting requirements.
Transformation Process
1
2
HFC

Product Manufactured
§84.31(e)(5)(iii)

1
2
3
4
Describe the transformation use. §84.31(e)(5)(i)

List and describe all technologies and actions taken to minimize emissions of HFCs. §84.31(e)(5)(ii)

Provide a list of any coproducts, byproducts, or emissions from the production line of any HFC that are other regulated sub
substances listed in 40 CFR part 82, subpart A, or hazardous air pollutants initially identified in Section 112 of the Clean Ai
rulemaking and codified in 40 CFR 63. §84.31(e)(5)(iv)

Provide the mass balance equation of the transformation reaction. §84.31(e)(5)(vii)

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 20
collection of information are mandatory (40 CFR 84.31). An agency may not conduct or sponsor, and a person is not required to resp
unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of informat
per response. Send comments on the Agency’s need this formation, the accuracy of the provided burden estimates and any sugges
respondent burden including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S. E
(2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not se
address.
EPA Form # 5900-542

OMB Control Number: 2060-XXXX
Expiration Date: X/XX/202X

g Act - HFC Transformation One-Time Reporting Form

sformation process performed at your facility. Provide supporting documentation, as needed, to
Transformation Process
3

4
Anticipated Ratio of HFC Used to Amount
Estimated Annual Fugitive Emissions(kg)
of End Product Manufactured§84.31(e)(5)
§84.31(e)(5)(v)
(vi)

nimize emissions of HFCs. §84.31(e)(5)(ii)

s from the production line of any HFC that are other regulated substances, ozone-depleting
us air pollutants initially identified in Section 112 of the Clean Air Act, and as revised through

eaction. §84.31(e)(5)(vii)

aperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-XXXX). Responses to this
ency may not conduct or sponsor, and a person is not required to respond to, a collection of information
ublic reporting and recordkeeping burden for this collection of information is estimated to be 100 hours
ation, the accuracy of the provided burden estimates and any suggested methods for minimizing
ection techniques to the Director, Regulatory Support Division, U.S. Environmental Protection Agency
60. Include the OMB control number in any correspondence. Do not send the completed form to this

Chemical Name
CHF3
CH2F2
CH3F
CF3CHFCHFCF2CF3
CHF2CF3
CHF2CHF2
CH2FCF3
CH2FCHF2
CH3CF3
CH2FCH2F
CH3CHF2
CF3CHFCF3
CH2FCF2CF3
CHF2CHFCF3
CF3CH2CF3
CH2FCF2CHF2
CF3CH2CF3
CF3CH2CF2CH3

Common Name
HFC-23
HFC-32
HFC-41
HFC-43-10mee
HFC-125
HFC-134
HFC-134a
HFC-143
HFC-143a
HFC-152
HFC-152a
HFC-227ea
HFC-236cb
HFC-236ea
HFC-236fa
HFC-245ca
HFC-245fa
HFC-365mfc