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

EPA Form # 5900-156, Revised 04/09 

### U.S. Environmental Protection Agency

STRATOSPH ERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

NOTIFICATION OF TRANSFERS OF ARTICLE 

### 5

ALLOWANCES 

### , ESSENTIAL



### - USE ALLOWANCES 

### , OR

ESSENTIAL



### - USE CFCS 

### (Sec 82.12)



## SECTION 1 TRANSFEROR/TRANSFEREE IDENTIFICATION

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 Company Information

Company Type (Select only one) Transferor (for Transfers of Arti cle 5 or Essential-Use Allowances)

Transferee (for Transfers of Essential-Use CFCs)
Company Name

Street Address

City State Zip Code



### 1.6 Company Contact Identification

Reporting Company Contact Person Phone Number Fax Number

E-mail Address



### 1.7 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



### U.S. Environmental Protection Agency

STRATOSPH ERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

NOTIFICATION OF TRANSFERS OF ARTICLE 

### 5

ALLOWANCES 

### , ESSENTIAL



### - USE ALLOWANCES 

### , OR

ESSENTIAL



### - USE CFCS 

### (Sec 82.12)



## SECTION 2.A TRANSACTION RECORD FOR TRANSFERS OF ARTICLE 5 (A5) ALLOWANCES OR ESSENTIAL-USE ALLOWANCES

(Reproduce additional sheets as needed)

TRANSACTION #

2.1 Transferee Identification

Transferee Company Name Transferee Contact Person

Street Address

City State Zip Code

Phone Number Fax Number

E-mail Address

Are Article 5 allowances or essential-use allowances being transferred? Article 5 Essential Use

2.2 Control Period for which Allowances Are Being Transferred (select only one) Current Year Allowances Baseline Year Allowances

2.3 Chemical Transferring From 2.4 ODP

2.5 Amount of Allowances of Chemical in Section 2.3 Being Transferred (kg)

2.6 Calculated Level of Chemical in Section 2.3 Being
Transferred (Section 2.4 x Section 2.5)

2.7 Chemical Transferring To 2.8 ODP

2.9 Amount of Offset (0.01 x Section 2.5) (kg)

2.10 Amount of Allowances Subtracted from Transferor’s Balance of Chemical Being Transferred (Section 2. 5 + Section 2.9) (kg)

2.11 Amount of Allowances of Chemical in Section 2.7 Being Received (Section 2. 6 ÷ Section 2.8) (kg)

2.12 For Essential-Use Allowance transfers, ha ve you included signed documentation from the transferee identifying the CFC MDI products th at will be produced using the Essential-Use Allowances (per Sec 82.12)? Yes No

EPA Form # 5900-156, Revised 04/09OMB Control Number: 2060-0170 Expiration Date: 4/30/12



### U.S. Environmental Protection Agency

STRATOSPH ERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

NOTIFICATION OF TRANSFERS OF ARTICLE 

### 5

ALLOWANCES 

### , ESSENTIAL



### - USE ALLOWANCES 

### , OR

ESSENTIAL



### - USE CFCS 

### (Sec 82.12)



## SECTION 2.B TRANSACTION RECORD FOR TRANSFERS OF ESSENTIAL-USE CFCS

(Reproduce additional sheets as needed)

TRANSACTION #

2.1 Transferor Identification

Transferor Company Name Transferor Contact Person

Street Address

City State Zip Code

Phone Number Fax Number

E-mail Address

2.2 Essential-Use CFC being tr ansferred (select only one) CFC-11 CFC-12 CFC-114

2.3 Amount of Essential-Use CFC in Section 2.2 being transferred (kg)

2.4 The specific Metered Dose Inhaler (MDI) products (i.e. the MDI drug product or active moiety) that the Transferee plans to produce with the transferred CFCs

2.5 The country(ies) where the CFC MDIs produced with the transferred Essential-Use CFCs will be sold if other than in the United States

2.6 Have you provided certification th at the Essential-Use CFCs will be used in the production of essen tial MDIs (per Sec 82.12)? Yes No

2.7 Have you submitted a letter by the transferor stating that it concurs with the terms of the transfer stated in your request (per Sec 82.12)? Yes No

EPA Form # 5900-156, Revised 04/09OMB Control Number: 2060-0170 Expiration Date: 4/30/12



### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

NOTIFICATION OF TRANSFERS OF ARTICLE 

### 5

ALLOWANCES 

### , ESSENTIAL



### - USE ALLOWANCES 

### , OR

ESSENTIAL



### - USE CFCS 

### (Sec 82.12)



## SECTION 3 UNEXPENDED BALANCE SUMMARY

3.1 Balance of Unexpended Allowances Prior to Transfers Reported

A B C

Chemical Name Balance of Unexpended Article 5 Allowances Balance of Unexpended Essential-Use Allowances for CFC use in Essential MDIs

CFC-11

CFC-12

CFC-13

CFC-111

CFC-112

CFC-113

CFC-114

CFC-115

Other CFCs (please specify)

EPA Form # 5900-156, Revised 04/09