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 W ere 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 submitte d 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 t he report when it is received by EPA, it may be made

public without further noti ce to the company (40 CFR 2.203)

.

The public reporting and recordkeeping burden for this collection of infor mation is estimated to average 2.4 hours per response. Send comments on the Agency's need for

this information, the accuracy of the provided burde n 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 Pen nsylvania 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 S UBSTANCE

LABORATORY CERTIFICA TION REPORT 

### (Sec 82.13)



## SECTION 1 LABORATORY IDENTIFICATION

1.1 Date of Submission 1.2 O riginal 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 applica tions and will not be

resold or used in man ufacturing.

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 infor mation, 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 DateOMB 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 S UBSTANCE

LABORATORY CERTI FICATION REPORT 

### (S ec 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 Chl oroform 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

Rea ction Solvent or Reaction Feedstock

....................................................... 

### B

. Analytical Uses and Regulated Applications

**Reference**

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

Tox icant...............................................................................................

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



### Extraction

Pesticide and Heavy Metal Detection

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

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

......................................................... 

### Diluen **t**

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 En gineering...........................................................................



### Miscellaneous (Including Testing)

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

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

...................................................... 

### C. Miscellaneous

**Laboratory Method Development**

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

........................................... %

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%



## SECTION 3 SUPPLIER IDENTIFICATION

3.1 Supplier Name