OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-153, Revised 04/11

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.

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY 

SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE 

ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission 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 (If 4th quarter is selected, Essential 

Use Holders should also submit Section 5 of 

this form.)

 1

st

 2

nd

 3

rd

 4

th Year 

1.6 Company Information

Company Name

Street Address

City State Zip Code 

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 
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-153, Revised 04/11

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY 

SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE 

ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

SECTION 2 QUARTERLY REPORT: 

For Essential-Use Allowance Holders and Distributors of Laboratory Supplies: 

Amounts Purchased/Received from Producers and/or Importers 

(Reproduce additional sheets as needed)

2.1 Company Name

2.2 Transaction Summaries 

TRANSACTION #

Source Company

Street Address

City State (U.S.) or Country Zip Code (U.S.)

Chemical Name of Class I Substance Purchased/Received Quantity of Class I Substance Purchased/Received (kg)

TRANSACTION #

Source Company

Street Address

City State (U.S.) or Country Zip Code (U.S.)

Chemical Name of Class I Substance Purchased/Received Quantity of Class I Substance Purchased/Received (kg)

TRANSACTION #

Source Company

Street Address

City State (U.S.) or Country Zip Code (U.S.)

Chemical Name of Class I Substance Purchased/Received Quantity of Class I Substance Purchased/Received (kg)
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-153, Revised 04/11

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY 

SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE 

ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

SECTION 3 QUARTERLY REPORT:

For Distributors of Laboratory Supplies: Amounts Supplied to Each Laboratory 

Customer Quarterly

(Reproduce additional sheets as needed)

3.1 Company Name

3.2 Quarterly Totals by Lab Customer

Amounts Supplied Quarterly per Lab

Lab Company

Street Address

City State Zip Code

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Amounts Supplied Quarterly per Lab

Lab Company

Street Address

City State Zip Code

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 

Class I Substance Supplied to Lab and Quantity: 

Substance: Quantity (kg): 
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-153, Revised 04/11

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY 

SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE 

ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

SECTION 4 QUARTERLY TOTALS BY CHEMICAL 

4.1 Company Name

4.2 Company Totals

A B C

Chemical Name Total Quantity of Essential Use Class I ODS 

Received from Producers/Importers (kg)

Total Quantity of Class I ODS 

Supplied to Labs (kg)

CFC-11

CFC-12

CFC-13

CFC-111

CFC-112

CFC-113

CFC-114

CFC-115

Other CFCs (please specify) 

HBFCs (please specify) 

Halons (please specify) 

Carbon Tetrachloride

Methyl Chloroform

CBM

Methyl Bromide
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-153, Revised 04/11

 U.S. Environmental Protection Agency 

 STRATOSPHERIC OZONE PROTECTION PROGRAM 

CLASS I CONTROLLED SUBSTANCE

ESSENTIAL USE ALLOWANCE HOLDERS & LABORATORY 

SUPPLIER QUARTERLY REPORT AND ESSENTIAL USE 

ALLOWANCE HOLDER ANNUAL REPORT (Sec 82.13)

SECTION 5 ANNUAL REPORT:

For 4th Quarter Essential Use Holder Reporting Only

(To be completed by the person allocated Essential-Use Allowances)

5.1 Distributor Name

5.2 Company Totals

A B C D E F G H I

Chemical 

Name

Amount 

Acquired by 

Production (kg)

Amount Acquired for Essential 

Uses by Import and Country(s) 

of Manufacture

Amounts On Hand 

at the End of the 

Year (includes pre1996 amounts) (kg)

Pre-phaseout 

Stockpiled 

Amounts Held

(kg)

Amounts Used 

for Essential 

Uses (kg)

Amount 

Contained in 

Exported 

Products (kg)

Amounts 

Destroyed or 

Recycled (kg)

Total Number of 

Marketable MDI 

Units Manufactured 

Amount (kg) Country

CFC-11

CFC-12

CFC-114