OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-152, Revised 01/11

SEND COMPLETED FORMS TO: The Company from Whom the 

Class I Substances Were Purchased

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 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 Pennsylvania 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

LABORATORY CERTIFICATION REPORT (Sec 82.13)

SECTION 1 LABORATORY IDENTIFICATION

1.1 Date of Submission 1.2 Original Submittal Re-submittal

1.3 Number of Class I Substances 

Reported 1.4 Number of Pages 

Submitted

1.5 Laboratory Information

Laboratory Name 

Street Address 

City State Zip Code 

1.6 Laboratory Contact Identification

Reporting Laboratory Contact Person Phone Number Fax Number 

E-mail Address 

1.7 Signature of Reporting Laboratory Representative

I certify that the quantities of controlled substances listed in this form are purchased solely for use in laboratory applications and will not be 

resold or used in manufacturing.

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 
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-152, Revised 01/11

 U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

LABORATORY CERTIFICATION REPORT (Sec 82.13)

SECTION 2 SUBSTANCE IDENTIFICATION AND USE

(Reproduce Additional Sheets as Needed)

2.1 Lab Name

2.2 Class I Substance (Select only one below)

CFC-11 CFC-12 CFC-13 CFC-111 CFC-112

CFC-113 CFC-114 CFC-115 Other CFC (please specify)

HBFC (please specify) Halon (please specify)

Carbon Tetrachloride Methyl Chloroform CBM Methyl Bromide

2.3 Amount of Class I Substance (kg)

2.4 Laboratory Applications (Select as many as apply and indicate percent use)

A. Research and Development

Reaction Solvent or Reaction Feedstock.......................................................

B. Analytical Uses and Regulated Applications

 Reference

Chemical.............................................................................................

Toxicant...............................................................................................

Product................................................................................................

 Extraction

Pesticide and Heavy Metal Detection.................................................

Product................................................................................................

Color & Food Additive Detection.........................................................

 Diluent

Zinc, Copper, Cadmium Detection in Plants and Food.......................

Microchemical Methods to Determine Molecular Weight of Oxygen...

Measuring Drug Purity and Residual Information................................

Sterilization of Lab Equipment............................................................

 Carrier (Inert)

Forensic Methods................................................................................

Titration...............................................................................................

Analytical Equipment...........................................................................

 Tracer

Sanitary Engineering...........................................................................

 Miscellaneous (Including Testing)

Ingredient in Material for Testing........................................................

Separation Media................................................................................

C. Miscellaneous

Laboratory Method Development.............................................

Sample Preparation Using Solvent...........................................

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SECTION 3 SUPPLIER IDENTIFICATION

3.1 Supplier Name