OMB Control Number: 2060
- 0170 Expiration Date : 4/30/12

EPA Form # 5900
- 150 , Revised 11 / 11



### U.S. Environmental Protection Agency **STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS I CONTROLLED S UBSTANCE **IMPORTER QUA RTERLY R**  **EPORT** 

### (S **e c**  **82. 13**  **)** 

## SECTION 1 **IMPORTING COMPA NY IDENTIFICA** **TION 1.1 Date of Submission**  **ions Reported 1.2**  **Original Submittal Re**  **- submittal**  **1.3 Number of Transactions Reported**  **1.4 Number of Pages Submitted**  **1. 5**  **Quarter and Year**  **to Which This Report A**  **pplies** 1 st 

### 2 nd 

### 3 rd 

### 4 th 

### Year **1. 6**  **Importing Company** Company Name
Street Address City State Zip Code Importer Number 

### 1. **7 Company Contact Identification**  Reporting Company Contact Person Phone Number Fax Number

E
- mail Address 

### 1. **8 Signature of Reporting Company Representative**  I certify under penalty of law that I have personally examined and am familiar with the information s ubmitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.
Name Title Signature Date


## SEND COMPLETED FORMS TO: **For U.S. Postal Service:** Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenue, NW Wa shington, DC 20460 **For Private Courier:** Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1310 L Street, N W ; 10 th Floor Wa shington, DC 20005 Information in reports submitted in compliance with the final rule may be claimed as confidential. A company may assert a claim of confidentiality for information submitted by clearl y marking that information as confidential. Such information shall be treated in accordance with EPA’s pr ocedures for information claimed as conf idential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confi dentiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2 .203)

. The public reporting and recordkeeping burden for this collection of infor mation is estimated to average 2.4 hours per response. Send comments on the Agency 's need for this information, the accuracy of the provided burden estimates, and any sugges ted methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T) , 1200 Pennsylvania Ave., NW , Wa shington, D.C. 20460. I nclude the OMB control number in any correspondence. Do not send the completed form to this address.OMB Control Number: 2060
- 0170 Expiration Date : 4/30/12

EPA Form # 5900
- 150 , Revised 11 / 11



### U.S. Environmental Protection Agenc y **STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS I CONTROLLED SUBSTANCE **IMP ORTER QUA**  **RTERLY REPO RT**  

### (S **ec 82.13)**  

## SECTION 2 TRA **NSA CTION RECORDS**  **(Reproduce additional sheets as needed) 2.1 Company Name**  **2.2 Transaction Summaries TRA**  **NSA CTION #**  Source Country Quantity of Commodity Imported (kg) Class I Substance Imported Quantity of Class I Substance Imported (kg) Port of Entry into the U.S. Date of Import ( mm/dd/yy) Customs Entry Summary Number Transaction Type (select one): New Used Heels If New: Transformation Destruction Gl obal Lab Essential
- Use Other Essential
- Uses (i.e., MDIs) If Used: Transformation Destruction Halon Aircraft Bottles Other Use; Date of Non
- Objection Notice (mm/dd/yy ) If Heels, it will: Remain in Container and Be

Included in Future Shipment Be Recovered and Transformed Be Recovered and Destroyed Be Recovered for a Non
- emissive Use 

### TR**AN SA**  **CTION #** Source Country Quantity of Commodity Imported (kg) Class I Substance Imported Quantity of Class I Substance Imported (kg) Port of En try into the U.S. Date of Import (mm/dd/yy) Customs Entry Summary Number Transaction Type (select one): New Used Heels If New: Transformation Destruction Global Lab Essential
- Use Other Essential
- Uses (i.e., MDIs) If Used: Transformation Destruction Halon Aircraft Bo ttles Other Use; Date of Non
- Objection Notice (mm/dd/yy) If Heels, it will: Remain in Container and Be

Included in Future Shipment Be Recovered and Transformed Be Recovered and Destroyed Be Recovered for a Non
- emissive Use 

### TR**AN SA**  **CTION #** Source Country Quantity of Commodity Imported (kg) Class I Substance Imported Quantity of Class I Substance Imported (kg) Port of En try into the U.S. Date of Import (mm/dd/yy) Customs Entry Summary Number Transaction Type (select one): New Used Heels If New: Transformation Destruction Global Lab Essential
- Use Other Essential
- Uses (i.e., MDIs) If Used: Transformation Destruction Halon Aircraft Bo ttles Other Use; Date of Non
- Objection Notice (mm/dd/yy) If Heels, it will: Remain in Container and Be

Included in Future Shipment Be Recovered and Transformed Be Recovered and Destroyed Be Recovered for a Non
- emissive UseOMB Control Number: 2060
- 0170 Expiration Date : 4/30/12

EPA Form # 5900
- 150 , Revised 11 / 11



### U.S. Environmental Protection Agency **STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS I CONTROLLED SUBSTANCE **IMPORTER QUA RTERLY R**  **EPORT** 

### (S **ec 82.13)**  

## SECTION 3 **COMPA NY IMPORT DA** **TA 3.1 Company Name**  **3.2 Compan y Import Totals**  **(kg) A**  **B C**  **D E**  **F G**  **H I** 
Chemical Name (Commodity Code) Essential
- Uses In
- House Transformation Second
- Party

Transformation In
- House

Destruction Second
P arty Destruction Gross Imports

of Class I Substance (B+ C+ D+ E+ F= G) Imports of

“Used” C lass I Substance Import of

Class I “Heels” Global Laboratory Exemption Other

Essential
- Use Exem ption (i.e., MDIs) CFC
- 11 (2903.41.0000) CFC
- 12 (2903.42.0000) CFC
- 1 3 (2903.45.0000) CFC
- 1 11 (2903.45.0000) CFC
- 1 12 (2903.45.0000) CFC
- 1 13 (2903.43.0000) CFC
- 1 14 (2903.44.0010) CFC
- 11 5 (2903.44.0020) Other CFCs and Commodity Code ( specify)

HBFC s (2903.49.9060) ( specify)

Halon s (2903.46.0000) ( specify ) Car bon Tetrachloride (2903.14.0000) Methyl Chloroform (2903.19.6010) CBM (2903.49.1000)