OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

REQUEST FOR ADDITIONAL CLASS II

CONSUMPTION ALLOWANCES

(Sec 82.20)

SECTION 1 EXPORTING COMPANY IDENTIFICATION

1.1 Date of Submission 1.2 Number of Transactions 

Reported

1.3 Number of Pages 

Submitted 1.4 Original Submittal Re-submittal

NOTE: ATTACH ALL BILLS OF LADING AND INVOICES SHOWING NET QUANTITY SHIPPED AND DOCUMENTING THE SALE

1.5 Exporting Company

Company Name

Street Address 

 

City State 

 

Zip Code 

Exporter 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 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 # 5900-201, Revised 9/12 
OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

REQUEST FOR ADDITIONAL CLASS II

CONSUMPTION ALLOWANCES

(Sec 82.20)

SECTION 2 TRANSACTION RECORDS

 (Reproduce additional sheets as needed)

2.1 Company Name

2.2 Transaction Summaries

TRANSACTION #

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 allowances): Date Purchased 

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

 

TRANSACTION #

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 allowances): Date Purchased 

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

 

TRANSACTION #

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 allowances): Date Purchased 

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

 

EPA Form # 5900-201, Revised 9/12 
OMB Control Number: 2060-0498

Expiration Date: TBD

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS II CONTROLLED SUBSTANCE

REQUEST FOR ADDITIONAL CLASS II

CONSUMPTION ALLOWANCES

(Sec 82.20)

SECTION 3 COMPANY EXPORT TOTALS

3.1 Company Name

3.2 Company Request Summary

A B

Chemical Name

(Commodity Code)

Total Consumption Allowances Requested (kg)

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 imported with expended allowances.

EPA Form # 5900-201, Revised 9/12