OMB
#
2060­
0170
Expiration
Date:
8/
31/
05
U.
S.
Environmental
Protection
Agency
STRATOSPHERIC
OZONE
PROTECTION
PROGRAM
CLASS
I
CONTROLLED
SUBSTANCE
REPORT:
EXPORTER
ANNUAL
REPORT
(
Sec
82.13(
h)
AND
Sec
82.13(
f)(
3)(
vi
and
ix))

SECTION
1
EXPORTING
COMPANY
IDENTIFICATION
1.1
Date
of
Submission
1.2
Number
of
Transactions
Reported
1.3
Number
of
Pages
Submitted
1.4
Year
to
Which
This
Report
Applies:
Year
1.5
Exporting
Company
Information
Company
Name
Street
Address
City
State
Zip
Code
1.6
Company
Contact
Identification
Reporting
Company
Contact
Person
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:
Tracking
System
Program
Manager
Global
Programs
Division
U.
S.
EPA
(
6205J)
1200
Pennsylvania
Avenue,
NW
Washington,
DC
20460
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).

Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
16
hours
per
response.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
The
OMB
control
numbers
for
EPA's
regulations
are
listed
in
40
CFR
Part
9
and
48
CFR
Chapter
15.
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,
OPPE
Regulatory
Information
Division,
U.
S.
Environmental
Protection
Agency
(
2137),
1200
Pennsylvania
Avenue,
NW,
Washington,
D.
C.
20460;
and
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Officer
for
EPA.
Include
the
EPA
ICR
number
and
OMB
control
number
in
any
correspondence.
DO
NOT
SEND
THIS
FORM
TO
THE
ABOVE
ADDRESS.
ONLY
SEND
COMMENTS
TO
THESE
ADDRESSES.

ICR
NUMBER
1432.22­
E­
1,
Revised
5/
05
OMB
#
2060­
0170
Expiration
Date:
8/
31/
05
U.
S.
Environmental
Protection
Agency
STRATOSPHERIC
OZONE
PROTECTION
PROGRAM
CLASS
I
CONTROLLED
SUBSTANCE
REPORT:
EXPORTER
ANNUAL
REPORT
(
Sec
82.13(
h)
AND
SEC
82.13(
f)(
3)(
vi
and
ix))

SECTION
2
TRANSACTION
RECORDS
(
Reproduce
additional
sheets
as
needed)
2.1
Company
Name
2.2
Transaction
Summaries
TRANSACTION
#

Recipient
Company
Name
Street
Address
City
Country
Postal
Code
Article
5
Country
Company
Contact
Person
Phone
Number
Fax
Number
Commodity
Code
of
Shipment
Quantity
of
Commodity
Exported
(
kg)

Class
I
Substance
Exported
Quantity
of
Class
I
Substance
Exported
(
kg)

Date
of
Export
(
mm/
dd/
yy)
Port
of
Export
from
the
U.
S.
Exporter
EIN
Number
from
Customs
Form
7525
Transformation
Destruction
Article
5
TRANSACTION
#

Recipient
Company
Name
Street
Address
City
Country
Postal
Code
Article
5
Country
Company
Contact
Person
Phone
Number
Fax
Number
Commodity
Code
of
Shipment
Quantity
of
Commodity
Exported
(
kg)

Class
I
Substance
Exported
Quantity
of
Class
I
Substance
Exported
(
kg)

Date
of
Export
(
mm/
dd/
yy)
Port
of
Export
from
the
U.
S.
Exporter
EIN
Number
from
Customs
Form
7525
Transformation
Destruction
Article
5
TRANSACTION
#

Recipient
Company
Name
Street
Address
City
Country
Postal
Code
Article
5
Country
Company
Contact
Person
Phone
Number
Fax
Number
Commodity
Code
of
Shipment
Quantity
of
Commodity
Exported
(
kg)

Class
I
Substance
Exported
Quantity
of
Class
I
Substance
Exported
(
kg)

Date
of
Export
(
mm/
dd/
yy)
Port
of
Export
from
the
U.
S.
Exporter
EIN
Number
from
Customs
Form
7525
Transformation
Destruction
Article
5
ICR
NUMBER
1432.22­
E­
2,
Revised
5/
05
OMB
#
2060­
0170
Expiration
Date:
8/
31/
05
U.
S.
Environmental
Protection
Agency
STRATOSPHERIC
OZONE
PROTECTION
PROGRAM
CLASS
I
CONTROLLED
SUBSTANCE
REPORT:
EXPORTER
ANNUAL
REPORT
(
Sec
82.13(
h)
AND
SEC
82.13(
f)(
3)(
vi
and
ix))

SECTION
3
COMPANY
EXPORT
TOTALS
(
Reproduce
Additional
Sheets
as
Needed)

3.1
Company
Name
3.2
Transaction
Summaries
Class
I
Substance
(
Select
only
one
below)

CFC­
11
CFC­
12
CFC­
13
CFC­
111
CFC­
112
CFC­
113
CFC­
114
CFC­
115
Other
CFC
(
please
specify)

HBFC
(
please
specify)
Halon
(
please
specify)

Carbon
Tetrachloride
Methyl
Chloroform
CBM
Country
Exported
To
Quantity
of
Class
I
Substance
Exported
(
kg)

ICR
NUMBER
1432.22­
E­
3,
Revised
5/
05
