Petition to Import for Transformation or Destruction

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OMB Control Numbe

American Innovation and Manufacturing Act - Petition to Import for Transformation or Destruct
Worksheet Instructions:

If your company intends to import HFCs for use in a process resulting in transformation or destruction, complete this reporting form
it to EPA through EPA's electronic Greenhouse Gas Reporting Tool (e-GGRT) at least 30 days before the shipment is to arrive at
Sections 1-3 and 5 must be completed prior to submission. Section 4 must also be completed if your company intends to have an
company hold the imported HFCs prior to their destruction or transformation; if not, Section 4 may be left blank.

EPA may request additional information or ask follow up questions to verify the accuracy of this submission and supporting docum
including pursuant to CAA section 114 as authorized under the AIM Act.
Version:
r0.10
Updated:
12/13/2021
External Links:
HFC Allocation Rule Reporting HelpDesk
AIM Act Paperwork Reduction Act Burden
Reporting Form Navigation:
Section 1 - Company Information Section 4 - Transformation and Destruction Intermediary Information
Section 2 - Import Information
Section 5 - Transformation and Destruction Facility Information
Section 3 - Shipment Information

Section 1 - Company Information
Instructions: Complete the following company information.
Company Name:
Company ID:
Importer Number:
Form Alias:

Section 2 - Import Information

Instructions: Provide the following information for the shipment you are petitioning to import. As part of your submission
application for an export license, or official communication acknowledging the export from the appropriate government a
Import Information
1
2
3
Vessel Name
Expected Year of Import
Expected Month of Import
§84.25(a)(1)(v)
§84.25(a)(1)(v)
§84.25(a)(1)(v)

Should the export license, application for an export license, or official communication acknowledging the export from the
appropriate government agency in the country of export be treated as confidential business information (CBI)?

C
1
Company Name
§84.25(a)(1)(iii)

2
Contact Name
§84.25(a)(1)(iii)

3
Contact Phone
§84.25(a)(1)(iii)

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and
information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden includin
1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
EPA Form # 5900-536

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

sformation or Destruction

on, complete this reporting form and submit
ore the shipment is to arrive at a U.S. port.
r company intends to have an intermediary
e left blank.

mission and supporting documentation,

duction Act Burden

t. As part of your submission, additionally provide an English translation of the export license,
he appropriate government agency in the country of export (§84.25(a)(1)(viii)).
nformation
4
5
6
Intended Port of Entry
Source Country
Intended Use
§84.25(a)(1)(v)
§84.25(a)(1)(iv)

wledging the export from the
information (CBI)?
Consignee Information
4
5
Street
Address
Contact Email
§84.25(a)(1)(iii)
§84.25(a)(1)(iii)

6
City
§84.25(a)(1)(iii)

7
State/U.S. Territory
§84.25(a)(1)(iii)

501 et seq. (OMB Control No. 2060-0735). Responses to this collection of information are mandatory (40 CFR 84.25). An agency may not conduct or
mber. The public reporting and recordkeeping burden for this collection of information is estimated to be 2 hours per response. Send comments on th
ing respondent burden including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S. Environmental
respondence. Do not send the completed form to this address.

8
Zip
§84.25(a)(1)(iii)

9
Country
§84.25(a)(1)(iii)

n agency may not conduct or sponsor, and a person is not
ponse. Send comments on the Agency’s need for this
Division, U.S. Environmental Protection Agency (2821T),

OMB Control Numbe
Expiration Dat

American Innovation and Manufacturing Act - Petition to Import for Transformation or Destruct
Worksheet Instructions:

If your company intends to import HFCs for use in a process resulting in transformation or destruction, complete this reporting form
it to EPA through EPA's electronic Greenhouse Gas Reporting Tool (e-GGRT) at least 30 days before the shipment is to arrive at
Sections 1-3 and 5 must be completed prior to submission. Section 4 must also be completed if your company intends to have an
company hold the imported HFCs prior to their destruction or transformation; if not, Section 4 may be left blank.

EPA may request additional information or ask follow up questions to verify the accuracy of this submission and supporting docum
including pursuant to CAA section 114 as authorized under the AIM Act.
Version:
r0.10
Updated:
12/13/2021
External Links:
HFC Allocation Rule Reporting HelpDesk
AIM Act Paperwork Reduction Act Burden
Reporting Form Navigation:
Section 1 - Company Information Section 4 - Transformation and Destruction Intermediary Information
Section 2 - Import Information
Section 5 - Transformation and Destruction Facility Information
Section 3 - Shipment Information

Section 3 - Shipment Information

Instructions: Provide the following information for each shipment you are petitioning to import. If a container contains m
substance, identify the type and quantity of each HFC in a separate row. If the shipment includes more than one containe
contained in each container in a separate row.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

1

2

Unique Identification Number of
Container
§84.25(a)(1)(x)

Container Capacity
(kg)
§84.25(a)(1)(ix)

Shipment Information
3
U.S. Customs Entry
Number

4

HFC to be Imported
§84.25(a)(1)(i)

24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

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

mation or Destruction

omplete this reporting form and submit
e shipment is to arrive at a U.S. port.
mpany intends to have an intermediary
blank.

on and supporting documentation,

a container contains more than one regulated
more than one container, enter the amount of each HFC

5

6

HTS Code
§84.25(a)(1)(i)

Quantity Imported
(kg)
§84.25(a)(1)(i)

OMB Control Numb

American Innovation and Manufacturing Act - Petition to Import for Transformation or Destruct
Worksheet Instructions:

If your company intends to import HFCs for use in a process resulting in transformation or destruction, complete this reporting form
it to EPA through EPA's electronic Greenhouse Gas Reporting Tool (e-GGRT) at least 30 days before the shipment is to arrive at
Sections 1-3 and 5 must be completed prior to submission. Section 4 must also be completed if your company intends to have an
company hold the imported HFCs prior to their destruction or transformation; if not, Section 4 may be left blank.

EPA may request additional information or ask follow up questions to verify the accuracy of this submission and supporting docum
including pursuant to CAA section 114 as authorized under the AIM Act.
Version:
r0.10
Updated:
12/13/2021
External Links:
HFC Allocation Rule Reporting HelpDesk
AIM Act Paperwork Reduction Act Burden
Reporting Form Navigation:
Section 1 - Company Information Section 4 - Transformation and Destruction Intermediary Information
Section 2 - Import Information
Section 5 - Transformation and Destruction Facility Information
Section 3 - Shipment Information

Section 4 - Transformation and Destruction Intermediary Information

Instructions: Provide the following information for each intermediary who will hold the material before the HFCs are trans
Intermediar
1
2
3
4
Company Name
Contact Name
Contact Phone
Contact Email
§84.25(a)(1)(vi)
§84.25(a)(1)(vi)
§84.25(a)(1)(vi)
§84.25(a)(1)(vi)
1
2
3
4

Should the intermediary information be treated as confidential business information (CBI)?

Section 5 - Transformation and Destruction Facility Information

Instructions: Provide the following information for each facility where the imported HFCs will be transformed or destroyed
T&D Facilit
1
2
3
4
Company Name
Contact Name
Contact Phone
Contact Email
§84.25(a)(1)(vii)
§84.25(a)(1)(vii)
§84.25(a)(1)(vii)
§84.25(a)(1)(vii)
1
2
3
4

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

ormation or Destruction

complete this reporting form and submit
the shipment is to arrive at a U.S. port.
ompany intends to have an intermediary
eft blank.

ssion and supporting documentation,

before the HFCs are transformed or destroyed, if applicable. If there is no intermediary, the table may be left blank
Intermediary Information
5
6
7
8
Street Address
City
State/U.S. Territory
Zip
§84.25(a)(1)(vi)
§84.25(a)(1)(vi)
§84.25(a)(1)(vi)
§84.25(a)(1)(vi)

e transformed or destroyed. These may be facilities owned or operated by the importer, or facilities owned and operated by other persons.
T&D Facility Information
5
6
7
8
Facility Street Address
Facility City
Facility State/U.S. Territory
Facility Zip
§84.25(a)(1)(vii)
§84.25(a)(1)(vii)
§84.25(a)(1)(vii)
§84.25(a)(1)(vii)

nk
9

Country
§84.25(a)(1)(vi)

perated by other persons.
9

Facility Country
§84.25(a)(1)(vii)