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 per sonally examined and am familiar with the information submitted in this and all a ttached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the info rmation, I believe t hat the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false in formation, 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; 10 th Floor Washington, DC 20005

Information in reports subm itted in compliance with the final rule may be clai med as confidential. A company may assert a clai m of confidentiality for information submitted by clearly marking that informat ion as confidential. Such information s hall be treated in accordance with EPA’s proc edures for information claimed as confidential at 40 CFR Part 2, Subpart B, and will only be disclo sed by the means set forth in th e subpart. If no claim of con fidentiality 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 es timates, and any suggested methods for minimizing respondent b urden, including through the use of automated collection techniques to the Direct or, 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