OMB Control Number: 2060
- 0170 Expiration Date: 4/30/12

EPA Form # 5900
- 151 , Revised 11 / 11



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

### CLASS I CONTROLLED S UBSTANCE **PRODUCER QUA RTERLY R**  **EPORT**



### (S **ec 82.13 )**  

## SECTION 1 PRODUCING COMPA **NY IDENTIFICA TION**  **1.1 Date of Submission 1.2**  **Original Submittal Re**  **- submittal**  **1. 3**  **Producing Company** Company Name
Street Address City State Zip Code 

### 1. **4 Company Contact Identification**  Reporting Company Contact Person Phone Number Fax Number E
- mail Address 

### 1. **5 Quarter**  **and Year to**  **Which This Report A**  **pplies** 1 st 2 nd 3 rd 4 th Year 

### 1. **6 Importer Information**  Is your company an I mporter of C lass I substances? If yes, is the I mporter Quarterly Repor t attached? Yes Yes No

No 

### 1. **7 Exporter Information**  Is your company an Ex porter of C lass I substances? If yes, is the Ex porter Quarterly Report attached? Yes Yes No

No 

### 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 do cuments, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe t hat the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting fa ls e information, including the possibility of fine and imprisonment. Name Title Signature Date

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 clearl y marking that information as confidential. Such information shall be treated in accordance with EPA’s pr ocedures for information claimed as conf idential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confi dentiality 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 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 sugges ted 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 , Wa shington, D.C. 20460. I nclude the OMB control number in any correspondence. Do not send the completed form to this address. 

## 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 20005OMB Control Number: 2060
- 0170 Expiration Date: 4/30/12

EPA Form # 5900
- 151 , Revised 11 / 11 

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

### CLASS I CONTROLLED S UBSTANCE **PRODUC ER QUA**  **RTERLY REPORT**



### (S **ec 82.13)** 

## SECTION 2 COMPA **NY PRODUCTION DATA 2.1 Company Name**  **2.2 Company Production Totals**

**A B**  **C D**  **E F**  **G**
Chemical Name Essential
- Uses In
- House Transformatio n (kg) Second
- Party Transformation (kg) In
- House Destruction (kg) Second
- Party

Destruction (kg) Gross Production of Class I Substance (B + C + D + E + F = G )

(kg) **B1** Global Laboratory Exemption (kg) **B2**

Other Essential
- Uses (i.e., MDI) (kg) CFC
- 11 CFC
- 12 CFC
- 13 CFC
- 111 CFC
- 112 CFC
- 113 CFC
- 11 4 CFC
- 11 5 Other CFCs (please specify)
HBFCs (please spe cify)

Halons (please specify)

Carbon Tetrachloride Methyl Chloroform CBM