OMB Control Nu mber: 2060
- 0498 Expiration Date: TBD 

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

### CLASS II CONTROLLED SUBSTANCE **PRODUCER QUA RTERLY R**  **E PORT** 



### (S **ec 82.24)** 

## SECTION 1 PRODUCING COMPA **NY IDENTIFICA TION**  **1.1 Date of Submission 1.2**  **Original Submittal Re**  **- submittal**  **1. 3**  **Quarter and Year to Which This Report A**  **pplies** 1 st 2 nd 3 rd 4 th Year 

### 1. **4 Producing Company**  Company Name
Street Address City State Zip Code 

### 1. **5 Company Contact Identification**  Reporting Company Contact Person Phone Number Fax Number E
- mail Address 

### 1. **6 Importer Information**  Is your company an importer of class II substances? If yes, is the Importer Quarterly Report attached? Yes Yes No

No 

### 1. **7 Exporter Information**  Is your company an ex porter of class II substances? If yes, is the Exporter Quarterly Report attached? Yes Yes No

No 

### 1. **8 Signature of Reporting Company Representative**  I certify under penalty of law that I have p ersonally 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, N W 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 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 w ith EPA’s procedures for information claimed as confi dential 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 compan y (40 CFR 2. 203). 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 suggest ed methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmen tal Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. In clude the OMB control number in any correspondence. Do not send the completed form to this address. EPA Form # 5900
- 202 , Revised 9/12OMB Control Number: 2060
- 0498 Expiration Date: TBD 

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

### CLASS II CONTROLLED SUBSTANCE **PRODUCER QUA RTERLY R**  **EPORT**



### (S **ec 82.24)** 

## SECTION 2 COMPA **NY PRODUCTION DA TA**  **2.1 Company Name 2.2 Company Production Totals**  **A B**  **C D**  **E F**  **G H**  **I**

Chemical Name Gross Production (kg) In
- House

Transformation (kg) Secon d
- Party

Transformation (kg) In
- House Destruction (kg) Second
- Party

Destruction (kg) HCFC
- 141b

Exemption (kg) Article 5 Production (kg) Net Production (kg)

(B
- C
- D
- E
- F
- G
- H = I) HCFC
- 22 HCFC
- 123 HCFC
- 124 HCFC
- 141b HCFC
- 142b HCFC
- 225ca HCFC
- 225cb If needed, please write in HCFC not listed above

EPA Form # 5900
- 202 , Revised 9/12OMB Control Numbe r : 20 60
- 0498 Expiration Date: TBD U.S. Environmental Protection Agen cy **STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS II CONTROLLED SUBSTANCE **PRODUCER QUA RTERLY R**  **EPORT**



### (S **ec 82.24 )**  

## SECTION 3 **AL LOW**  **ANCE EXPENDITURE TOTA**  **LS**

**3.1 Company Name 3.2**  **Al lowance Balance Summary**  **A B**  **C D** 
Chemical Name Total p roduction allowances for year

to date (as of the end of the quarter)

that were: Total consumption allowances for year to date (as of the end of the quarter)

that were: Total Article 5 allowances for year to date (as of the end of the quarter) that

were: Ex pended Unexpended Ex pended Unexpended Ex pended Unexpended HCFC
- 22 HCFC
- 123 HCFC
- 124 HCFC
- 142b HCFC
- 225ca HCFC
- 225cb If needed , please write in HCFC not listed above



### 3.3 Name(s) of HCFC **- 141b Exemption A**  **llowance Holder(s) from whom Orders were R**  **eceived and A ssociated**  **Quantity (kg) of HCFC -**  **141b Requested and Produced**  Company Name: HCFC
- 141b Requested and Produced (kg) : Company Name: HCFC
- 141b Requested and Produced (kg) : Company Name: HCFC
- 141b Requested and Produced (kg) : Com pany Nam e: HCFC
- 141b Requested and Produced (kg) : Company Name: HCFC
- 141b Requested and Produced (kg) : EPA Form # 5900
- 202 , Revised 9/12