OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

EXPORTER QUARTERLY REPORT

(Sec 82.24)

SECTION 1 EXPORTING COMPANY IDENTIFICATION

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 Applies: 1

st

 2

nd 3rd 4th Year 

1.6 Exporting Company

Company Name 

Street Address 

City State Zip Code 

Exporter 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 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 4.5 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.

EPA Form # 5900-199, Revised 9/12 
OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

EXPORTER QUARTERLY REPORT

(Sec 82.24)

SECTION 2 TRANSACTION RECORDS

 (Reproduce additional sheets as needed)

2.1 Company Name

2.2 Transaction Summaries

TRANSACTION #

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 Production 

and Consumption Allowances 

If none apply, 

check here

Exporting Vessel on which export was shipped: 

(Complete if Article 5 allowances is selected above)

TRANSACTION #

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 Production 

and Consumption Allowances 

If none apply, 

check here

Exporting Vessel on which export was shipped: 

(Complete if Article 5 allowances is selected above)

EPA Form # 5900-199, Revised 9/12
OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

EXPORTER QUARTERLY REPORT

(Sec 82.24)

SECTION 3 COMPANY EXPORT TOTALS

 (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