Document ID: EPA-HQ-OAR-2003-0039-0038
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2016-04-28T04:00Z

SEQ CHAPTER \h \r 1 	OMB Control Number: 2060-0498

	Expiration Date: TBD

   	U.S. Environmental Protection Agency

            stratospheric ozone protection program	class ii controlled
substance

request for additional class ii 

consumption allowances

      	1.2  Number of Transactions Reported	  FORMTEXT 
      

1.3  Number of Pages Submitted	  FORMTEXT        	1.4      
FORMCHECKBOX   Original Submittal         FORMCHECKBOX   Re-submittal

NOTE: ATTACH ALL BILLS OF LADING AND INVOICES SHOWING NET QUANTITY
SHIPPED AND DOCUMENTING THE SALE

1.5 Exporting Company

Company Name    FORMTEXT                                    

Street Address    FORMTEXT          

City    FORMTEXT        	State    FORMTEXT          
  	Zip Code    FORMTEXT        

Exporter EIN from Customs Form 7525    FORMTEXT        

1.6 Company Contact Identification

Reporting Company Contact Person    FORMTEXT        

E-mail Address    FORMTEXT        

Phone Number    FORMTEXT        	Fax Number    FORMTEXT 
      

1.7 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    FORMTEXT        

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 # 5900-201, Revised 10/12    SEQ CHAPTER \h \r 1 	OMB Control
Number: 2060-0498

	Expiration Date: TBD

        U.S. Environmental Protection Agency

             stratospheric ozone protection program	class ii controlled
substance

request for additional class ii

consumption allowances

      			

2.2 Transaction Summaries	

TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        

Street Address    FORMTEXT        

City    FORMTEXT        	Country    FORMTEXT        
Postal Code    FORMTEXT        

Company Contact Person    FORMTEXT        	Phone Number   
FORMTEXT        	Fax Number    FORMTEXT        

Port of Export from the U.S.    FORMTEXT        	Date of
Export (mm/dd/yy)    FORMTEXT        

HCFC Exported   FORMTEXT        	Quantity of HCFC Exported
(kg)   FORMTEXT        

If Produced in the U.S.:	Company that produced the HCFC (expending
production and consumption allowances):    FORMTEXT        

If Imported:	Company that imported HCFC (expending consumption
allowances), AND country imported from:    FORMTEXT        

Date Purchased (Complete if the company that exported the HCFC is not
the same company that produced the HCFC):   FORMTEXT        

愀Ĥ摧甓S

摧䱫^

Œ

Ž

¿

@

D

N

P

l

 l

n

p

Š

Ž

؀

$

&

:

<

J

P

R

\

^

`

t

v

x

‚

„

„

†

”

–

ª

¬

®

¸

º

Ä

Æ

Ú

Ü

ð

ò

ô

þ

jŽ

j/

㐀ۖĀ̊xᤃ替Ĵ瑹䱫^咊

摧䄒T

摧䄒T

愀Ĥ摧曖Ù

¼ÿÍ

¼ÿÍ

摧䄒TԀ.    FORMTEXT        	Date of Export (mm/dd/yy)   
FORMTEXT        

HCFC Exported   FORMTEXT        	Quantity of HCFC Exported
(kg)   FORMTEXT        

If Produced in the U.S.:	Company that produced the HCFC (expending
production and consumption allowances):    FORMTEXT        

If Imported:	Company that imported HCFC (expending consumption
allowances), AND country imported from:    FORMTEXT        

Date Purchased (Complete if the company that exported the HCFC is not
the same company that produced the HCFC):   FORMTEXT        

TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        

Street Address    FORMTEXT        

City    FORMTEXT        	Country    FORMTEXT        
Postal Code    FORMTEXT        

Company Contact Person    FORMTEXT        	Phone Number   
FORMTEXT        	Fax Number    FORMTEXT        

Port of Export from the U.S.    FORMTEXT        	Date of
Export (mm/dd/yy)    FORMTEXT        

HCFC Exported   FORMTEXT        	Quantity of HCFC Exported
(kg)   FORMTEXT        

If Produced in the U.S.:	Company that produced the HCFC (expending
production and consumption allowances):    FORMTEXT        

If Imported:	Company that imported HCFC (expending consumption
allowances), AND country imported from:    FORMTEXT        

Date Purchased (Complete if the company that exported the HCFC is not
the same company that produced the HCFC):   FORMTEXT        

EPA Form # 5900-201, Revised 10/12  		

OMB Control Number: 2060-0498

		Expiration Date: TBD  SEQ CHAPTER \h \r 1 

     U.S. Environmental Protection Agency

         stratospheric ozone protection program	class ii controlled
substance

request for additional class ii

consumption allowances

(Sec 82.20)

SECTION 3    COMPANY EXPORT TOTALS

3.1 Company Name	  FORMTEXT        

3.2 Company Request Summary	

A	B

Chemical Name 

(Commodity Code)	Total Consumption Allowances Requested (kg)

HCFC-22 

(2903.71.0000)	  FORMTEXT        

HCFC-142b

(2903.74.0000)	  FORMTEXT        

HCFC-123

(2903.72.0020)	  FORMTEXT        

HCFC-124 

(2903.79.9030)	  FORMTEXT        

HCFC-225ca

(2903.75.0000)	  FORMTEXT        

HCFC-225cb

(2903.75.0000)	  FORMTEXT        

Please note: This form must be accompanied by a written statement from
the producer that the class II controlled substances were produced with
expended allowances or a written statement from the importer that the
class II controlled substances were imported with expended allowances.

EPA Form # 5900-201, Revised 10/12