OMB Control Number: 2060-0170 

Expiration Date: 4/30/12 

EPA Form # 5900-148, Revised 04/09

 U.S. Environmental Protection Agency 

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

SECOND-PARTY DESTRUCTION

ANNUAL REPORT (Sec 82.13)

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of 

Submission 

1.2 Year To 

Which This 

Report Applies

 1.3 Original Submittal 

 Re-submittal

1.4 Have you submitted a one-time destruction report to 

EPA (per Sec 82.13)? Yes No Date Submitted: 

1.5 Have you submitted a destruction verification to the 

producer or importer (per Sec 82.13)? Yes No Date Submitted: 

1.6 Company Information 

Company Name 

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 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.
OMB Control Number: 2060-0170 

Expiration Date: 4/30/12 

EPA Form # 5900-148, Revised 04/09

 U.S. Environmental Protection Agency 

 STRATOSPHERIC OZONE PROTECTION PROGRAM

CLASS I CONTROLLED SUBSTANCE

SECOND-PARTY DESTRUCTION

ANNUAL REPORT (Sec 82.13)

SECTION 2 DESTRUCTION SUMMARY

2.1 Company Name 

2.2 Destruction Totals

A B

Chemical Name Second-Party Destruction of Class I Substance (kg)

CFC-11 

CFC-12 

CFC-13 

CFC-111 

CFC-112 

CFC-113 

CFC-114 

CFC-115 

Other CFCs (please specify) 

 

 

HBFCs (please specify) 

 

 

Halons (please specify) 

 

 

Carbon Tetrachloride 

Methyl Chloroform 

CBM