5900-542 HFC Transformation One-Time Report

				OMB Control Number: 2060-0734
				Expiration Date: 12/31/2024
	American Innovation and Manufacturing Act - HFC Transformation One-Time Report
	Worksheet Instructions:
	Complete and submit an HFC Transformation One-Time Report if your company transforms regulated HFCs. Information on only one facility may be reported per reporting form. All sections of the report must be completed prior to submission. Provide supporting documentation, as needed, to respond to these reporting requirements.
	Version:
	r0.2
	Updated:
	3/16/2022
	External Links:
	HFC Allocation Rule Reporting HelpDesk		AIM Act Paperwork Reduction Act Burden
	Reporting Form Navigation:
	Section 1 - Facility Identification
	Section 2 - Transformation Process Information
	EPA may request additional information or ask follow up questions to verify the accuracy of this submission and supporting documentation, including pursuant to CAA section 114 as authorized under the AIM Act.
	Section 1 - Facility Identification
	Instructions: Complete the following Facility information.
	Company Name:
	Facility Name:
	Facility ID:
	Section 2 - Transformation Process Information
	Instructions: Provide the following information on the transformation process performed at your facility. Provide supporting documentation, as needed, to respond to these reporting requirements.
	Transformation Process
	1	2	3	4
	HFC	Product Manufactured §84.31(e)(5)(iii)	Estimated Annual Fugitive Emissions (%) §84.31(e)(5)(v)	Anticipated Ratio of HFC Used to Amount of End Product Manufactured (%) §84.31(e)(5)(vi)
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2
3
4
	Describe the transformation use. §84.31(e)(5)(i)
	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 line on which the HFC is to be transformed that are other regulated substances, ozone-depleting substances listed in 40 CFR part 82, subpart A, or hazardous air pollutants initially identified in Section 112 of the Clean Air Act, and as revised through 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. 2060-0734). Responses to this collection of information are mandatory (40 CFR 84.31). 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 100 hours per response. Send comments on the Agency’s need for this information, 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 # 5900-542