Form 5900-204 CLASS II CONTROLLED SUBSTANCE SECOND-PARTY TRANSFORMATIO

OMB Control Number: 2060-0498

Expiration Date: TBD

U.S. Environmental Protection Agency stratospheric ozone protection program

class ii controlled substance second-party transformation annual report (Sec 82.24)

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission

     

1.2 Year To Which This Report Applies

     

1.3 Original Submittal Re-submittal

1.4 Have you submitted a transformation verification to the producer or importer (per Sec 82.24)?

Yes No

Date Submitted:

     

1.5 Company Information

Company Name      

Street Address      

City      

State      

Zip Code      

1.6 Company Contact Identification

Reporting Company Contact Person      

E-mail Address      

Phone Number      

Fax Number      

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      

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, 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 # 5900-204, Revised 10/12

OMB Control Number: 2060-0498

Expiration Date: TBD

U.S. Environmental Protection Agency stratospheric ozone protection program		class ii controlled substance second-party transformation annual report (Sec 82.24)
SECTION 2 TRANSFORMATION SUMMARY
2.1 Company Name	     
2.2 Transformation Totals
A			B
Chemical Name			Quantity Transformed (kg)
HCFC-22			     
HCFC-123			     
HCFC-124			     
HCFC-141b			     
HCFC-142b			     
HCFC-225ca			     
HCFC-225cb			     
If needed, please write in HCFCs not listed above			     
     			     
     			     
     			     
     			     
     			     
     			     
     			     
     			     

EPA Form # 5900-204, Revised 10/12