Application for Set-aside of HFC Allowances

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American Innovation and Manufacturing Act - Application for Set-aside of HFC Allo
Worksheet Instructions:

Use this workbook to provide EPA with information to be eligible for consideration for HFC allowances from the set-aside pool. Info

Persons who qualify for set-aside allowances because they are application-specific end-users
Persons who qualify for set-aside allowances because they are new market entrants
Persons who qualify for set-aside allowances because they imported regulated substances in 2020 but were not required to report
Version:
1.1
Updated:
11/23/2021
External Link:

Final Rule - Phasedown of Hydrofluorocarbons: Establishing the Allowance Allocation and Trading Program Under the American In
Reporting Form Navigation:
Section 1 - Company Identification
Section 2a - Application-Specific Use Information
Section 2b - Application-Specific Use Projections
Section 2c - Contracting Information
Section 3a - New Market Entrant Information
Section 3b - Plan for Importing HFCs
Section 3c - Certifications

EPA may request additional information or ask follow up questions to verify the accuracy of this submission and supporting docum

Section 1 - Company Identification

Instructions: Complete the following company information for the company that is applying for allowances under the HFC
Company Name
Street Address

Instructions: Provide the URL for your company's website, if available.
Website URL

Instructions: Provide information on the corporate structure of the company. Describe the complete ownership of the com
owners, and identify any subsidiaries. Provide supporting documentation to verify the information provided. Documentat
Publicly traded/listed on X stock exchange, LLC, Privately held Limited Partnership, Incorporated in X State), identifying
incorporated/registered, and/or documentation of the officers for each legal entity. §84.15(d)

Instructions: Provide the following information for the designated representative at the company. §84.15(d)
Designated Representative
Contact Name
Contact Email

Instructions: Select the reason your company is eligible for set-aside allowances.

Reason for Eligibility

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a cur
collection of information is estimated to be 44 hours per response. Send comments on the Agency’s need for this information, the
respondent burden including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S
20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form # 5900-534

Application for Set-aside of HFC Allowances

sideration for HFC allowances from the set-aside pool. Information must be provided by November 30, 2021. Submit this completed form along with a

ation-specific end-users should complete Sections 1 and 2 of this reporting form.
arket entrants should complete Sections 1 and 3 of this reporting form.

gulated 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 comple

nce Allocation and Trading Program Under the American Innovation and Manufacturing Act <https://www.federalregister.gov/documents/2021/10/05/2

erify the accuracy of this submission and supporting documentation, including pursuant to CAA section 114 as authorized under the AIM Act.

company that is applying for allowances under the HFC Allowance Set-aside. §84.15(d)
City
State/U.S. Territory
Zip

able.

e company. Describe the complete ownership of the company, including percentages of ownership and the name of the parent company or
entation to verify the information provided. Documentation may include articles of incorporation and a description of the incorporation (e.g
mited Partnership, Incorporated in X State), identifying number or registration associated with the company in the jurisdiction where
each legal entity. §84.15(d)

representative at the company. §84.15(d)
ve
Contact Phone

de allowances.

k Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0735). Responses to this collection of information are mandatory (40 CFR 84.15). An
spond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this
d comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing
echniques to the Director, Regulatory Support Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.
t send the completed form to this address.

OMB Control Number: 2060-0735
Expiration Date: 4/30/2022

by November 30, 2021. Submit this completed form along with any supporting documentation to EPA through the ODS Tracking System (ODSTS). In

d were not issued allowances as of October 1, 2021, must complete Section 1 of this form and submit it through the ODSTS and provide EPA with the

ing Act <https://www.federalregister.gov/documents/2021/10/05/2021-21030/phasedown-of-hydrofluorocarbons-establishing-the-allowance-allocation-

nt to CAA section 114 as authorized under the AIM Act.

Country

ntages of ownership and the name of the parent company or
s of incorporation and a description of the incorporation (e.g.,
associated with the company in the jurisdiction where

o this collection of information are mandatory (40 CFR 84.15). An
umber. The public reporting and recordkeeping burden for this
burden estimates and any suggested methods for minimizing
n Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C.

American Innovation and Manufacturing Act - Application for Set-aside of HFC Allow
Version:
1.1
Updated:
11/23/2021
External Link:

Final Rule - Phasedown of Hydrofluorocarbons: Establishing the Allowance Allocation and Trading Program Under the American Inn
Reporting Form Navigation:
Section 1 - Company Identification
Section 2a - Application-Specific Use Information
Section 2b - Application-Specific Use Projections
Section 2c - Contracting Information
Section 3a - New Market Entrant Information
Section 3b - Plan for Importing HFCs
Section 3c - Certifications

Section 2a - Application-Specific Use Information

Instructions: Entities that qualify for application-specific allowances under § 84.13 that were not issued allowances as of O
Instructions: Select from the dropdown menu the application your company uses.

Instructions: Provide a description of the use of regulated substances and a detailed explanation of how the use is an appl

Should the description of the use of regulated substances and a detailed explanation of how the use is an application-spec
listed in §84.31(a) be treated as confidential business information (CBI)?

Instructions: Provide the total quantity of all regulated substances acquired for application-specific use in the previous thr
Provide a copy of the sales records, invoices, or other records documenting that quantity. Make sure to specify the HFC w
cylinder or unit if not included in the sales records or invoices. §84.31(h)(2)(ii)
HFC
Quantity Aquired in 2018 (kg)
Quantity Aquired in 2019 (kg)

Instructions: Provide the name of the entity or entities supplying regulated substances for application-specific use and con
Supplier Inform
Company Name
Contact Name
Contact Phone

Instructions: Provide the quantities of regulated substances held in inventory for application-specific use as of June 30 of
HFC Inventory
Quantity held in Inventory as of Quantity held in Inventory as of
HFC
June 30, 2020 (kg)
June 30, 2021 (kg)

Instructions: Describe plans to transition to regulated substances with a lower exchange value or alternatives to regulated

Section 2b - Application-Specific Use Projections

Instructions: If requesting additional allowances due to one or more of the circumstances listed in § 84.13(b)(1), provide a
calendar year. §84.31(h)(2)(vi)
Regulated Substance
Month
Quan
January 2022
February 2022
March 2022
April 2022
May 2022
June 2022
July 2022
August 2022
September 2022
October 2022
November 2022
December 2022
TOTAL
0.00
0.00

Instructions: Provide a detailed explanation, including relevant supporting documentation (e.g., explanation of amounts of
when the new line or facility is opening, more recent sales numbers to document growth in MDI sales resulting from a pub

Section 2c - Contracting Information

Does your company contract out the manufacturing of defense sprays or metered dose inhalers, or contract out the servic

Instructions: If applicable, provide the contact information for a representative of the person(s) contracted to do the manuf
Manufacturing/Servicing
Company Name
Contact Name
Contact Phone

Instructions: Provide clarification on whether the responses provided in Sections 2a and 2b above apply to the company t
and/or servicing using application-specific allowances. §84.31(h)(2)(vii)

OMB Control Number: 2060-0735
Expiration Date: 4/30/2022

or Set-aside of HFC Allowances

ding Program Under the American Innovation and Manufacturing Act <https://www.federalregister.gov/documents/2021/10/05/2021-21030/phasedown

were not issued allowances as of October 1, 2021 must provide the information requested below.

xplanation of how the use is an application-specific use listed in §84.31(a). §84.31(h)(2)(i)

f how the use is an application-specific use

tion-specific use in the previous three years.
ity. Make sure to specify the HFC weight per
Quantity Aquired in 2020 (kg)

for application-specific use and contact information for those suppliers. §84.31(h)(2)(iii)
Supplier Information
Contact Email
City
State/U.S. Territory

Zip

cation-specific use as of June 30 of this year and the prior year. §84.31(h)(2)(iv)

ge value or alternatives to regulated substances. §84.31(h)(2)(v)

ces listed in § 84.13(b)(1), provide a projection of the monthly quantity of each additional regulated substance needed by month in the next

Quantity of Projected Needs (kg)

0.00

0.00

0.00

ion (e.g., explanation of amounts of products that must be delivered under new contracts, copies of permits or other documentation to clar
th in MDI sales resulting from a public health emergency) to justify the additional need. §84.31(h)(2)(vi)

inhalers, or contract out the servicing of onboard aerospace fire suppression?

erson(s) contracted to do the manufacturing or servicing. §84.31(h)(2)(vii)
Manufacturing/Servicing Representative
Contact Email
City

State/U.S. Territory

Zip

nd 2b above apply to the company that is requesting application-specific allowances or the company receiving the contract for manufacturi

Country

tance needed by month in the next

0.00

mits or other documentation to clarify

Country

ceiving the contract for manufacturing

American Innovation and Manufacturing Act - Application for Set-aside of HFC Allow

Version:
1.1
Updated:
11/23/2021
External Link:
Final Rule - Phasedown of Hydrofluorocarbons: Establishing the Allowance Allocation and Trading Program Under the American In

Section 1 - Company Identification
Section 2a - Application-Specific Use Information
Section 2b - Application-Specific Use Projections
Section 2c - Contracting Information
Section 3a - New Market Entrant Information
Section 3b - Plan for Importing HFCs
Section 3c - Certifications

Section 3a - New Market Entrant Information

Instructions: Persons who are seeking to become a new market entrant (i.e., new importer), do not share corporate or com
past five years, or familial relations with entities receiving allowances, and were not eligible for allowances as of October
requested below. Companies must demonstrate an ability to make use of allowances. Further, companies without a detai
exporter will not be eligible to receive allowances from the set-aside pool.

Contact Name

Is the company a woman or minority
owned businesss. §84.15(d)(2)(ii)

Owner of the Company §84.15(d)(2)(iii)
Contact Email

Date of Incorporation §84.15(d)(2)
(iv)

How many allowances is your company requesting (in metric tons of exchange value equivalent (MTEVe))?
For a calculator to convert kilograms of HFCs to MTEVe, please visit <https://www.epa.gov/climate-hfcs-reduction/phasedown-hydr

Section 3b - Plan for Importing HFCs
Instructions: Provide the following information detailing the company's plan for importing HFCs. §84.15(d)(2)(vi)
Instructions: Describe what equipment and facilities the company has or needs to acquire to manage compressed gases.

Does the company currently sell HFCs or other industrial gases?
Does the company have any past experience importing HFCs?
If yes, has the company reported prior imports to the Greenhouse Gas
Reporting Program?
If you responded yes to either question above, describe your experience.

Will the company be working with a customs broker?
If yes, which brokerage firm?
Provide contact information for the brokerage firm.
Instructions: Indicate the month(s) in which the company intends to import HFCs.
Month
Intend to Import HFCs
January
February
March
April
May
June
July
Augus
September
October
November
December
Instructions: Identify the single component HFC(s) the company intends to import and the CAS number for each.
Intended HFC Imports
HFC
CAS Number

Instructions: Identify the HFC blends the company intends to import and the ASHRAE numerical designation of the refrige
HFC Component (1)
HFC Blend

HFC

Instructions: Identify the HTS codes for the HFCs and HFC blends the company intends to import.
HTS Codes

Instructions: Identify the prospective foreign exporter that the applicant anticipates working with and provide confirmatio
exporter that the timeline for imports is accurate and achievable. §84.15(d)(2)(vii)

Does your submission include supporting documentation from the foreign exporter confirming that the timeline for imports is
accurate and achievable?

Section 3c - Certifications
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:
The company intends to import HFCs in calendar years 2022 and 2023.

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”.

The company has read the HFC Allocation final rule, available by visiting <https://www.federalregister.gov/documents/2021/10/05/2
40 CFR 84.5 Prohibitions relating to regulated substances.
40 CFR 84.15 Set-aside of application-specific allowances, production allowances, and consumption allowances.
40 CFR 84.19 Transfers of allowances.
40 CFR 84.23 Certification identification generation and tracking.
40 CFR 84.31(a), (c), (h), and (k) Recordkeeping and reporting.
40 CFR 84.33 Auditing of recordkeeping and reporting.
40 CFR 84.35 Administrative consequences.
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.
The company will pay any duties conistent with U.S. Customs and Border Protection (CBP) requirements per Title 19.
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)
The information submitted in this form is complete, accurate, and truthful. §84.15(d)(2)(ix)

OMB Control Number: 2060-0735
Expiration Date: 4/30/2022

Application for Set-aside of HFC Allowances

nce Allocation and Trading Program Under the American Innovation and Manufacturing Act<https://www.federalregister.gov/documents/2021/10/05/20

ntrant (i.e., new importer), do not share corporate or common ownership, corporate affiliation in the
ces, and were not eligible for allowances as of October 1, 2021, must provide the information
use of allowances. Further, companies without a detailed import plan and a prospective foreign
de pool.

15(d)(2)(iii)
Contact Phone

State in which Company is
Incorporated §84.15(d)(2)(iv)

State License Identifier
§84.15(d)(2)(v)

of exchange value equivalent (MTEVe))?
ttps://www.epa.gov/climate-hfcs-reduction/phasedown-hydrofluorocarbons-hfcs-issuing-allowance-allocations>.

any's plan for importing HFCs. §84.15(d)(2)(vi)

has or needs to acquire to manage compressed gases.

reported prior imports to the Greenhouse Gas

irm?
ion for the brokerage firm.

o import HFCs.

tends to import and the CAS number for each.

rt and the ASHRAE numerical designation of the refrigerant or the percentage of the mixture containing each regulated substance and the C
Intended HFC Blend Imports
HFC Component (1)
HFC Component (2)
HFC Composition
HFC Composition of Blend (%)
CAS Number
HFC
of Blend (%)

the company intends to import.

licant anticipates working with and provide confirmation from the foreign
84.15(d)(2)(vii)

gn exporter confirming that the timeline for imports is

s an individual designated by the company with
ertifying the following:

Documentation Provided?

on ownership, corporate affiliation in the past five
e rule entitled, "Phasedown of Hydrofluorocarbons:
American Innovation and Manufacturing Act”.

g <https://www.federalregister.gov/documents/2021/10/05/2021-21030/phasedown-of-hydrofluorocarbons-establishing-the-allowance-allocation-and-tr

on allowances, and consumption allowances.

n (DOT) standards and all cylinders and containers
t CFR Title 49 part §178.

er Protection (CBP) requirements per Title 19.

tablished under the AIM Act and annual Greenhouse

ul. §84.15(d)(2)(ix)

gulated substance and the CAS numbers for each neat HFC.

mponent (2)
CAS Number

HFC

HFC Component (3)
HFC Composition
of Blend (%)

CAS Number