OMB Contro l Number: 2060

- 0 498 Expiration Date: TBD 

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

### CLAS S II CONTROLLED SUBS TANCE **REQUEST FOR A DDITION**  **AL CLA**  **SS II CONSUMPTION A**  **LLOW AN**  **C ES**  

### ( **S ec**  **82. 2**  **0 )**  

## SECTION 1 EXPORTING COMPA **NY IDENTIFICA TION**  **1.1 Date of Submission 1.2 Number of Transactions**  **Reported 1.3 Number of Pages**  **Submitted 1.4**  **Original Submittal Re**  **- submittal** 
**NOTE: A**

**TTA CH**  **AL L BILLS OF LA**  **DING A ND INVOICES SHOWING NET QUA**  **NTI TY**  **SHIPPED A ND DOCUMENTING THE SA**  **LE** 

### 1. **5 Exporting Company**  Company Name Street Address
City State Zip Code
Ex porter EIN from Customs Form 7525 

### 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 immediatel y 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.
N ame 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 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 infor mation 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 respon se. Send comments on the Agency's need for this information, the accuracy of the provided burden est im ates, and any suggested 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, Wash ington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. EPA Form # 5900

- 201 , Revised 9/12OMB Control Nu mber: 2060

- 0 498 Expiration Date: TBD


### U.S. Enviro nm ental Protection Agency
**STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS II CONTROLLED SUBSTANCE **REQUEST FOR A DDITION**  **AL CLA**  **SS II CONSUMPTION A**  **LLOW AN**  **C ES**  

### (S **ec 82.20 )**  

## SECTION 2 TRA **NSA CTION RECORD**  **S**

**(Reproduce addit ional sheets as needed)**  **2.1 Company Name 2.2 Transaction Summaries**  **TRA NSA**  **CTION #** Recipient Company Name Street Address City Country Postal Code Company Contact Person Phone Number Fax Number Quantity of Commodity Exported (kg) HCFC Chemical Exported Quantity of HCFC Exported (kg) Dat e of Export (mm/dd/yy) Port of Export from the U.S. Select One : (a) Company that produced the HCFC (expending production and consumption allowances ): Date Purchased

(b) Company that imported HCFC (expending consumption allowances), AND country imported from:



### TRA **NSA CTION #**  Recipient Company Name Street Address City Country Postal Code Company Contact Person Phone Number Fax Number Quantity of Commodity Exported (kg) HCFC Chemical Exported Quantity of HCFC Exported (kg) Date of Export (mm/dd/yy) Port of Export from the U.S. Select One: (a) Company that produced the HCFC (expending production and consumption all owances): Date Purchased

(b) Company that imported HCFC (expending consumption allowances), AND country imported from:



### TRA **NSA CTION #**  Recipient Company Name Street Address City Country Postal Code Company Contact Person Phone Number Fax Number Quanti ty of Commodity Exported (kg) HCFC Chemical Exported Quantity of HCFC Exported (kg) Date of Export (mm/dd/yy) Port of Export from the U.S. Select One: (a ) Company that produced the HCFC (expending production and consumption allowances): Date Purchased

(b) Company that imported HCFC (expending consumption allowances), AND country imported from:
EPA Form # 5900

- 201 , Revised 9/12OMB Control N um ber: 2060

- 0 498 Expiration Date: TBD 

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

### CLASS II CONTROLLED SUBSTANCE **REQUEST FOR A DDIT**  **IONA L**  **CLA SS II**  **CONSUMPTION A LLOW**  **AN C**  **ES**

**(S ec**  **82.20 )**  

## SECTION 3 COMPA **NY EXPORT TOTA**  **LS 3.1 Company Name**  **3.2 Company Request Summary**  **A B**  Chemical Name (Commodity Code) Total Consumption Allowances Requested (k g )
HCFC

- 22 ( 2903. 71 .0000 ) HCFC

- 142b ( 2903. 74.0000 ) HCFC

- 123 (2903. 72.0020 ) HCFC

- 124 (2903. 79.9030 ) HCFC

- 225ca (2903. 75.0000 ) HCFC

- 225cb (2903. 75.0000 ) 

### Please note: This form must be accompanied by a written statement from the producer that the class II controlled **substances were produced with expended allowances or a written statement from the importer that the class II controlled substances were impo**  **rted with expended allowances.** EPA Form # 5900

- 201 , Revised 9/12