OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-150, Revised 11/11

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE 

IMPORTER QUARTERLY REPORT

(Sec 82.13)

SECTION 1 IMPORTING COMPANY IDENTIFICATION

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 Applies 1

st

 2

nd

 3

rd 4th 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 submitted 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

Washington, DC 20460

For Private Courier:

Tracking System Program Manager

Stratospheric Protection Division

U.S. EPA (6205J)

1310 L Street, NW; 10th Floor

Washington, 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 clearly marking that information as confidential. Such information shall be treated in accordance with EPA’s procedures for information claimed as 

confidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confidentiality 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 information 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 suggested 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, 

Washington, D.C. 20460. Include 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 Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM 

CLASS I CONTROLLED SUBSTANCE

IMPORTER QUARTERLY REPORT 

(Sec 82.13)

SECTION 2 TRANSACTION RECORDS (Reproduce additional sheets as needed)

2.1 Company Name

2.2 Transaction Summaries

TRANSACTION #

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 Global 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

TRANSACTION #

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 Global 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

TRANSACTION #

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 Global 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
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-150, Revised 11/11

 U.S. Environmental Protection Agency 

 STRATOSPHERIC OZONE PROTECTION PROGRAM 

CLASS I CONTROLLED 

SUBSTANCE

IMPORTER QUARTERLY REPORT 

(Sec 82.13)

SECTION 3 COMPANY IMPORT DATA

3.1 Company Name

3.2 Company 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

SecondParty 

Destruction

Gross Imports 

of Class I 

Substance 

(B+ C+ D+ E+ 

F= G)

Imports of 

“Used” 

Class I 

Substance

Import of 

Class I 

“Heels”

Global 

Laboratory 

Exemption 

Other 

Essential-Use 

Exemption 

(i.e., MDIs)

CFC-11

(2903.41.0000)

CFC-12

(2903.42.0000)

CFC-13 

(2903.45.0000)

CFC-111 

(2903.45.0000)

CFC-112 

(2903.45.0000)

CFC-113 

(2903.43.0000)

CFC-114 

(2903.44.0010)

CFC-115 

(2903.44.0020)

Other CFCs and 

Commodity Code

(specify)

HBFCs 

(2903.49.9060)

(specify)

Halons

(2903.46.0000)

(specify)

Carbon 

Tetrachloride

(2903.14.0000)

Methyl 

Chloroform

(2903.19.6010)

CBM 

(2903.49.1000)