Document ID: EPA-HQ-OAR-2003-0039-0024
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2012-09-12T04:00Z

OMB Control
Number: 2060-0498

                                                                        
                                                                        
                                    Expiration Date: TBD

     U.S. Environmental Protection Agency

          stratospheric ozone protection program	class ii controlled
substance 

producer quarterly report

 (Sec 82.24)

SECTION 1    PRODUCING COMPANY IDENTIFICATION

	1.1 Date of Submission	  FORMTEXT        	   1.2   
FORMCHECKBOX  Original Submittal    FORMCHECKBOX   Re-submittal

1.3 Quarter and Year to Which This Report Applies	  FORMCHECKBOX   1st	 
FORMCHECKBOX   2nd	  FORMCHECKBOX   3rd	  FORMCHECKBOX   4th	Year  
FORMTEXT          FORMTEXT        

1.4 Producing Company

	Company Name    FORMTEXT        

Street Address   FORMTEXT        

City    FORMTEXT           	State    FORMTEXT       
	Zip Code    FORMTEXT        

1.5 Company Contact Identification

Reporting Company Contact Person

  FORMTEXT        	Phone Number

  FORMTEXT        	Fax Number

  FORMTEXT        

E-mail Address   FORMTEXT        

1.6 Importer Information	Is your company an importer of class II
substances?

If yes, is the Importer Quarterly Report attached?	  FORMCHECKBOX    Yes

  FORMCHECKBOX    Yes	  FORMCHECKBOX    No

  FORMCHECKBOX    No

1.7 Exporter Information	Is your company an exporter of class II
substances?

If yes, is the Exporter Quarterly Report attached?	  FORMCHECKBOX    Yes

  FORMCHECKBOX    Yes	  FORMCHECKBOX    No  

      

Title    FORMTEXT        

Signature     FORMTEXT        	Date      FORMTEXT 
      

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 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 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.

EPA Form # 5900-202, Revised 9/12                                      
                                                                        
                                                                        
              	 OMB Control Number: 2060-0498

                                                                        
                                                                        
                                                                        
                                               	Expiration Date: TBD

     U.S. Environmental Protection Agency

         stratospheric ozone protection program

	class ii controlled substance 

producer quarterly report 

(Sec 82.24)

 SECTION 2    COMPANY PRODUCTION DATA

	 2.1 Company Name	    FORMTEXT        

 2.2 Company Production Totals

A	B	C	D	E	F	G	H	I

Chemical Name	Gross Production (kg)	In-House Transformation (kg)
Second-Party Transformation (kg)	In-House Destruction (kg)	Second-Party
Destruction (kg)	HCFC-141b Exemption (kg)	Article 5 Production (kg)	Net
Production (kg)

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       	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
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EPA Form # 5900-202, Revised 9/12  

                                                                       
                                                                    OMB
Control Number: 2060-0498

                                                                        
                                                                        
                                            Expiration Date: TBD

  U.S. Environmental Protection Agency

stratospheric ozone protection program

class ii controlled substance 

producer quarterly report 

(Sec 82.24)

SECTION 3

ALLOWANCE EXPENDITURE TOTALS

	3.1 Company Name	  FORMTEXT        

 3.2 Allowance Balance Summary

A	B	C	D

Chemical Name	Total production allowances for year to date (as of the
end of the quarter) that were:	Total consumption allowances for year to
date (as of the end of the quarter) that were:	Total Article 5
allowances for year to date (as of the end of the quarter) that were:

	Expended	Unexpended	Expended	Unexpended	Expended	Unexpended

HCFC-22	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

HCFC-123	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

HCFC-124	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

HCFC-142b	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

HCFC-225ca	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

HCFC-225cb	  FORMTEXT        	  FORMTEXT        	 
FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

If needed, please write in HCFC not listed above   FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
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  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

3.3 Name(s) of HCFC-141b Exemption Allowance Holder(s) from whom Orders
were Received and Associated Quantity (kg) of HCFC-141b Requested and
Produced

Company Name:    FORMTEXT          	HCFC-141b Requested and
Produced (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Produced (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Produced (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Produced (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Produced (kg):   FORMTEXT         

EPA Form # 5900-202, Revised 9/12