OM B Control Numb er: 2060

- 0498 Expiration Date: TBD 

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

### CLASS II CONTROLLED SUBSTANCE **EXPORTER QUA**  **RTERLY REPORT**  

### (Sec 82. **24 )**  

## SECTION 1 EXPORTING COMPA **NY ID ENTIFICA**  **TION 1.1 Date of Submission**  **1.2 Number of Transactions Reported**  **1.3 Number of Pages Submitted 1.4**  **Original Submittal Re**  **- submittal**  **1.5 Quarter and Year to Which**  **This Report A pplies:**  1 st 

### 2 nd 

### 3 rd 

### 4 th 

### Year
**1.6 Exporting Company**  Company Name

Street Address
City State Zip Code Ex porter EIN from Customs Form 7525: 

### 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 t

he 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 c laimed 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 w ith EPA’s procedures for information claimed as confid ential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confide ntiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2.2 03). The public reporting and recordkeeping burden for this collection of information is estimated to average 4.5 hours per respon se. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggeste d methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protec tion Agency (2822T), 1200 Pennsylvania Ave., N W, W ashington, D.C. 20460. Inc lude the OMB control number in any correspondence. Do not send the completed form to this address. EPA Form # 5900

- 199 , Revised 9/12OMB Control Numb er: 2060

- 0 498 Expiration Date: TBD 

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

### CLASS II CONTROLLED SUBSTANCE **EXPORTER QUA**  **RTERLY REPORT** 

### (Sec 82. **24)** 

## SECTION 2 TRA **NSA CTION RECORDS** 

**(Reproduce additional sheets as needed) 2.1 Company Name**  **2.2 Transaction Summaries**
**TRA NSA**  **CTION #** Recipient Co mpany Name Street Address
City Country Postal Code Article 5 Country Company Contact Person Phone Number Fax Number Quantity of Commodity Exported (kg) If Export **is not** a Blend: HCFC : Qua ntity (kg) : If Export **is** a Blend: Name of Blend Quantity (kg) HCFC in Blend : Quantity (kg) : HCFC in Blend : Quantity (kg) : HCFC in Blend : Quantity (kg) : Date of Export (mm/dd/yy) Port of Export from the U.S. Sel ect One: New Used Select One: Transformation Destruction Produced with Article 5 Allowances Produced with Production and Consumption Allowances If none apply, check here Ex porting Vessel on which export was shipped: (Complete if Article 5 allowances is selected above) 

### TRA **NSA CTION #**  Recipient Company Name Street Address City Country Postal Code Article 5 Country Company Contact Person Phone Number Fax Number Quantity of Commodity Exported (kg) If Export **is not** a Blend: HCFC : Quantity (kg) : If Export **is** a Blend: Name of Blend Quantity (kg) HCFC in Blend : Quantity (kg) : HCFC in Blend : Quantity (kg) : HCFC in Blend : Quantity (kg) : Date of Export (mm/dd/yy) Port of Export from the U.S. Select One: New Used Select One: Transformation Destruction Produced with Article 5 Allowances Produced with Produc tion and Consumption Allowances If none apply, check here Ex porting Vessel on which export was shipped: (Complete if Article 5 allowances is selected above) EPA Form # 5900

- 199 , Revised 9/12OMB Control Numb er: 2060

- 0 498 Expiration Date: TBD 

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

### CLASS II CONTROLLED SUBSTANCE **EXPORT ER**  **QUA RTERLY REPORT**  

### (Sec 82. **24)** 

## SECTION 3 COMPA **NY EXPORT TOTA LS** 

**(Reproduce Additional Sheets as Needed)** 

### 3.1 Company Name **3.2 Transaction Summaries**
**Class II Substance**  **( Commodity Code**  **)** (Select only one below) HCFC

- 22 (2903. 71.0000 ) HCFC

- 123

( 2903.72.0020 ) HCFC

- 124

( 2903.79.9030 ) HCFC

- 142b

(2903.74.0000 ) HCFC

- 225ca

( 2903.75.0000 ) HCFC

- 225cb

( 2903.75.0000) HCFC and Commodity Code (if not listed above)

**Country Receiving**  **Export Quantity**  **of Class II**  **Substance Exported (kg)**

EPA Form # 5900

- 199 , Revised 9/12