OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

SECOND-PARTY TRANSFORMATION

ANNUAL REPORT (Sec 82.24)

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission 1.2 Year To Which This Report Applies

1.3 Original Submittal Re-submittal

1.4 Have you submitted a transformation verification to the 

producer or importer (per Sec 82.24)? Yes No Date Submitted:

1.5 Company Information

Company Name 

Street Address 

City State Zip Code 

1.6 Company Contact Identification

Reporting Company Contact Person Phone Number Fax Number

E-mail Address 

1.7 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 # 5900-204, Revised 9/12 
OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

SECOND-PARTY TRANSFORMATION

ANNUAL REPORT (Sec 82.24)

SECTION 2 TRANSFORMATION SUMMARY

2.1 Company Name

2.2 Transformation Totals

A B

Chemical Name Quantity Transformed (kg)

HCFC-22

HCFC-123

HCFC-124

HCFC-141b

HCFC-142b

HCFC-225ca

HCFC-225cb

If needed, please write in HCFCs not listed above 

EPA Form # 5900-204, Revised 9/12