OMB Control Number: 2060-0170

Expiration Date: 4/30/12

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 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.

EPA Form # 5900-149, Revised 11/11

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

EXPORTER ANNUAL REPORT 

(Sec 82.13) 

SECTION 1 EXPORTING COMPANY IDENTIFICATION

1.1 Date of Submission 1.2 Original Submittal Re-submittal

1.3 Number of Transactions Reported 1.4 Number of Pages Submitted

1.5 Year to Which This Report Applies: Year 

1.6 Exporting Company Information

Company Name 

Street Address 

City State Zip Code 

Exporter EIN from Customs Form 7525 

1.7 Company Contact Identification

Reporting Company Contact Person Phone Number Fax Number

E-mail Address 

1.8 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 
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

EPA Form # 5900-149, Revised 11/11

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

EXPORTER ANNUAL REPORT 

(Sec 82.13)

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) 

Class I Substance Exported Quantity of Class I Substance Exported (kg)

Date of Export (mm/dd/yy) Port of Export from the U.S. 

Transaction Type (select one): New Used

If New: Transformation Destruction Global Lab Use Other Essential-Uses 

(i.e., MDIs)

Produced with Prod/Cons 

Allowances

If Used: Transformation Destruction Halon Aircraft Bottles

TRANSACTION #

Recipient Company Name Street Address 

City Country Postal Code 

Company Contact Person Phone Number Fax Number 

Quantity of Commodity Exported (kg) 

Class I Substance Exported Quantity of Class I Substance Exported (kg)

Date of Export (mm/dd/yy) Port of Export from the U.S. 

Transaction Type (select one): New Used

If New: Transformation Destruction Global Lab Use Other Essential-Uses 

(i.e., MDIs)

Produced with Prod/Cons 

Allowances

If Used: Transformation Destruction Halon Aircraft Bottles

TRANSACTION #

Recipient Company Name Street Address 

City Country Postal Code 

Company Contact Person Phone Number Fax Number 

Quantity of Commodity Exported (kg) 

Class I Substance Exported Quantity of Class I Substance Exported (kg)

Date of Export (mm/dd/yy) Port of Export from the U.S. 

Transaction Type (select one): New Used

If New: Transformation Destruction Global Lab Use Other Essential-Uses 

(i.e., MDIs)

Produced with Prod/Cons 

Allowances

If Used: Transformation Destruction Halon Aircraft Bottles
OMB Control Number: 2060-0170

Expiration Date: 4/30/12

 U.S. Environmental Protection Agency

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

EXPORTER ANNUAL REPORT 

(Sec 82.13) 

SECTION 3 COMPANY EXPORT TOTALS 

(Reproduce additional sheets as needed)

3.1 Company Name

3.2 Transaction Summaries

Class I Substance

(Commodity Code)

(Select only one below)

CFC-11

(2903.41.0000)

CFC-12

(2903.42.0000)

CFC-13

(2903.45.0000)

CFC-111

(2903.45.0000)

CFC-112

(2903.45.0000)

CFC-113

(2903.43.0000)

CFC-114

(2903.44.0010)

CFC-115

(2903.44.0020)

Other CFC and 

Commodity 

Code (specify)

HBFC (specify)

(2903.49.9060)

Halon (specify)

(2903.46.0000)

Carbon Tetrachloride

(2903.14.0000)

Methyl Chloroform

(2903.19.6010)

CBM

(2903.49.1000)

Country Exported To Quantity of Class I Substance Exported (kg)

EPA Form # 5900-149, Revised 11/11