Document ID: EPA-HQ-OAR-2003-0039-0025
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

exporter quarterly report

      	1.2  Number of Transactions Reported	  FORMTEXT 
      

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

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

1.6 Exporting Company

	Company Name    FORMTEXT        

Street Address    FORMTEXT        

City    FORMTEXT        	State   FORMTEXT        
Zip Code   FORMTEXT        

Exporter EIN from Customs Form 7525:    FORMTEXT        

1.7 Company Contact Identification

Reporting Company Contact Person

  FORMTEXT        	Phone Number

  FORMTEXT        	Fax Number

      

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 # 5900-199, Revised 9/12    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

exporter quarterly report

(Sec 82.24)

SECTION 2    TRANSACTION RECORDS

      			

2.2 Transaction Summaries	

TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        	Street Address   
FORMTEXT        

City   FORMTEXT        	Country   FORMTEXT        
Postal Code   FORMTEXT        	  FORMCHECKBOX   Article 5
Country

Company Contact Person   FORMTEXT        	Phone Number  
FORMTEXT        	Fax Number   FORMTEXT        

Quantity of Commodity Exported (kg) 

  FORMTEXT        	If Export is not a Blend:

HCFC:   FORMTEXT                  Quantity (kg):   FORMTEXT 
      

If Export is a Blend:  Name of Blend   FORMTEXT               
                                                                   
Quantity (kg)   FORMTEXT        

HCFC in Blend:   FORMTEXT        

Quantity (kg):   FORMTEXT        	HCFC in Blend:   FORMTEXT 
      

Quantity (kg):   FORMTEXT        	HCFC in Blend:   FORMTEXT 
      

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(Complete if Article 5 allowances is selected above)

TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        	Street Address   
FORMTEXT        

City   FORMTEXT        	Country   FORMTEXT        
Postal Code   FORMTEXT        	  FORMCHECKBOX   Article 5
Country

Company Contact Person   FORMTEXT        	Phone Number  
FORMTEXT        	Fax Number   FORMTEXT        

Quantity of Commodity Exported (kg)

   FORMTEXT        	If Export is not a Blend:

HCFC:   FORMTEXT                  Quantity (kg):   FORMTEXT 
      

If Export is a Blend: Name of Blend   FORMTEXT                
                                                                        
   Quantity (kg)   FORMTEXT        

HCFC in Blend:   FORMTEXT         

Quantity (kg):   FORMTEXT        	HCFC in Blend:   FORMTEXT 
       

Quantity (kg):   FORMTEXT        	HCFC in Blend:   FORMTEXT 
       

Quantity (kg):   FORMTEXT        

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

Select One: 	  FORMCHECKBOX   New	  FORMCHECKBOX   Used

Select One:	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction
  FORMCHECKBOX   Produced with Article 5 Allowances	  FORMCHECKBOX  
Produced with Production and Consumption Allowances  	  FORMCHECKBOX  
If none apply, check here

Exporting Vessel on which export was shipped:    FORMTEXT 
      

(Complete if Article 5 allowances is selected above)

EPA Form # 5900-199, Revised 9/12	  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

exporter quarterly report

(Sec 82.24)

SECTION 3    COMPANY EXPORT TOTALS

                               (Reproduce Additional Sheets as Needed)

3.1 Company Name	  FORMTEXT        

3.2 Transaction Summaries

Class II Substance 

(Commodity Code)

(Select only one below)

  FORMCHECKBOX    HCFC-22

(2903.71.0000)	  FORMCHECKBOX    HCFC-123

(2903.72.0020)	  FORMCHECKBOX    HCFC-124

(2903.79.9030)	  FORMCHECKBOX    HCFC-142b

(2903.74.0000)	  FORMCHECKBOX    HCFC-225ca

(2903.75.0000)	  FORMCHECKBOX    HCFC-225cb

(2903.75.0000)

HCFC and Commodity Code (if not listed above)	  FORMTEXT 
      

Country Receiving Export	Quantity of Class II Substance Exported (kg)

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EPA Form # 5900-199, Revised 9/12