OMB Control Number: 2060
- 0498 Expiration Date: TBD 

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

### CLASS I I CONTROLLED SUBSTANCE **SECOND** 

### - **PA RTY DESTRUCTION**  **AN NUA** **L R EPORT**  

### (Sec 82.24 **)** 

## SECTION 1 **COMPANY IDENTIFICA TION**  **1.1 Date of Submission 1.2 Year To Which This Report A**  **pplies 1.3**  **Original Submittal Re**  **- submittal**  **1.4 Have you submitted a one**  **- time destruction report to**  **EPA (per Sec 82.24)?**  Yes No **Date Submitted: 1.5**  **Have you submitted a destruction verification to the producer or importer (per Sec 82.24)?**  Yes No **Date Submitted: 1.**  **6 Company Information**  Company Nam e
Street Address
City State Zip Code 

### 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 

## SEND COMPLETED FORMS TO: **For U.S. Postal Service:** Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenu e, 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 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 w ith EPA’s procedures for information claimed as c onfidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of co nfidentiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CF R 2.203). The public reporting and recordkeeping burden for this collection of in formation 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 auto mated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., N W, Wa shington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the c ompleted form to this address. EPA Form # 5900
- 203 , Revised 9/12OMB Control Number: 2060
- 0498 Expiration Date: TBD 

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

### CLASS I I CONTROLLED SUBSTANCE **SECO ND**  

### - **PA RTY DESTRUCTION**  **AN NUA** **L R**  **EPORT** 

### (Sec 82.24 **)** 

## SECTION 2 DESTRUCTION SUMMA **RY 2.1 Company Name**  **2.2 Destruction**  **Totals A**  **B** Chemical Name Quantity Destroyed (kg) HCFC
- 22 HCFC
- 123 HCFC
- 124 HCFC
- 141b HCFC
- 142b HCFC
- 225ca HCFC
- 225cb If needed, please write in HCFCs not listed above

EPA Form # 5900
- 203 , Revised 9/12