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 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 c laimed 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 confid ential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confide ntiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2.2 03)

. 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 burden estimates, and any suggeste d 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., N W, W ashington, D.C. 20460. Inc lude 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 Agenc y **STRA TOSPHERIC OZONE**  **PROTECTION PROGRA M**  

### CLASS I CONTROLLED SUBSTANCE **EXPORTER A NNUA**  **L REPO RT**  

### ( **Sec 82. 13)**  

## SECTION 1 EXPORTING COMPA **NY IDENTIFICA TION**  **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 A pplies:**  Year **1. 6**  **Exporting Company Information** Company Name Street Address City State Zip Code
Ex porter 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 p enalty 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 sub mitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false inf ormation, including the possibility of fine and imprisonment. Name Title Signature DateOMB Control Number: 2060
- 0170 Expiration Date: 4/30/12

EPA Form # 5900
- 149 , Revised 11 /11



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

### CLASS I CONTROLLE D SUBSTANCE **EXPORTER A NNUA**  **L REPO RT**  

### ( **Sec 82. 13)**  

## SECTION 2 **TRA NS**  **ACTION RECORDS (**  **Reproduce additional 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 Quan tity of Commodity Exported (kg) Class I Substance Exported Quantity of Class I Substance Ex ported (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 U se Other Essential
- Uses (i.e., MDIs) Produced with Prod/Cons Allowances If Used: Transformation Destruction Halon Aircraft Bottles 

### TRA **NSA CTION #**  Recipient Company Name Street A ddress 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 Ex ported (kg) Date of Export (mm/dd/yy) Port of Export from the U.S. Transaction Type (sel ect 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 

### TRA **NSA CTION #**  Recipient Company Name Street Address City Country Postal Code Company Contact Person Phone Number F ax Number Quantity of Commodity Exported (kg) Class I Substance Exported Quantity of Class I Substance Ex ported (kg) Date of Export (mm/dd/yy) Port of E xport from the U.S. Transaction Type (select one): New Used If New: Transformation Destruction Global Lab Use Ot her Essential
- Uses (i.e., MDIs) Produced with Prod/Cons Allowances If Used: Transformation Destruction Halon Aircraft BottlesOMB Control Number: 2060
- 0170 Expiration Date : 4/30/12 

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

### CLASS I CONTROLLED SUBSTANCE **EXPORTER A NNUA**  **L R EPORT**  

### ( **Sec 82. 13)**  

## SECTION 3 **COMPA NY EXPORT TOTA**  **LS (Reproduce additional sheets as n**  **eeded)** 

### 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 (2903.19.601 0) CBM (2903.49.1000) **Country Exported To**  **Quantity of Class I**  **Substance Exported (kg)**

EPA Form # 5900
- 149 , Revised 11 / 11