OMB Control Number: 2060

- 0170

Expiration Date: 4/30/12

EPA Form # 5900

- 153 , Revise d 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 ; 10 th 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 submitte d

by clearly marking that information as confidential. Such information shall be treated in accordance with EPA’s procedures f or i nformation 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 acco mpanies the report when it is received by EPA, it

may be made public without further notic e 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 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 Pen nsylvania 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

E SSENTIAL U SE A LLOWANCE H OLDERS 

### & L ABORATORY

S UPPLIER Q UARTERLY R EPORT AND E SSENTIAL U SE

A LLOWANCE H OLDER A NNUAL R EPORT 

### ( Sec 82. 13)



## SECTIO N 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 4 th 

### 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 attache d

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 DateOMB Control Number: 2060

- 0170

Expiration Date: 4/30/12

EPA Form # 5900

- 153 , Revise d 04 / 11



### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

E SSENTIAL U SE A LLOWANCE H OLDERS 

### & L ABORATORY

S UPPLIER Q UARTERLY R EPORT AND E SSENTIAL U SE

A LLOWANCE H OLDER A NNUAL R EPORT 

### ( Sec 82. 13)



## SECTION 2 QUARTERLY REPORT:

For Essential

- Use Allowance Holders and Distributors of Laboratory Supplies:

Amounts Purchased/Receive d 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 , Revise d 04 / 11 

### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLE D SUBSTANCE

E SSENTIAL U SE A LLOWANCE H OLDERS 

### & L ABORATORY

S UPPLIER Q UARTERLY R EPORT AND E SSENTIAL U SE

A LLOWANCE H OLDER A NNUAL R EPORT 

### ( Sec 82. 13)



## SECTION 3 QUARTERLY REPORT:

For Distributors of Laboratory Supplies: Amounts Supplied to Each Laboratory

Custom er 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 Su pplied to Lab and Quantity:

Substance: Quantity (kg ) : C lass 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 Suppli ed 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 , Revise d 04 / 11



### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

E SSENTIAL U SE A LLOWANCE H OLDERS 

### & L ABORATORY

S UPPLIER Q UARTERLY R EPORT AND E SSENTIAL U SE

A LLOWANCE H OLDER A NNUAL R EPORT 

### ( Sec 82. 13)



## SECTION 4 QUARTERLY TOTALS BY CHEMICAL

4.1 Company Name

4.2 Company T otals

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)

HBF Cs (please specify)

Halons (please specify)

Carbon Tetrachloride

Methyl Chloroform

CBM

Methyl BromideOMB Control Number: 2060

- 0170

Expiration Dat e: 4/30/12

EPA Form # 5900

- 153 , Revised 04 / 11



### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### C LASS I CONTROLLED SUBSTANCE

E SSENTIAL U SE A LLOWANCE H OLDERS 

### & L ABORATORY

S UPPLIER Q UARTERLY R EPORT AND E SSENTIAL U SE

A LLOWANCE H OLDER A NNUAL R EPORT 

### ( Sec 82. 13)



## SECTION 5 ANNUAL REPORT:

For 4 th 

## Quarter Essential Use Holder Reporting Only

(To be com pleted by the person allocated Essential

- Use A llowances)

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 pre

1996 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