OMB
Control
Number:
2060­
0498
Pending
Expiration
Date:
6/
30/
06
U.
S.
Environmental
Protection
Agency
STRATOSPHERIC
OZONE
PROTECTION
PROGRAM
CLASS
II
CONTROLLED
SUBSTANCE
EXPORTER
QUARTERLY
REPORT
(
Sec
82.24)

SECTION
1
EXPORTING
COMPANY
IDENTIFICATION
1.1
Date
of
Submission
1.2
Number
of
Transactions
Reported
1.3
Number
of
Pages
Submitted
1.4
Quarter
and
Year
to
Which
This
Report
Applies:
1
st
2
nd
3
rd
4
th
Year
1.5
Exporting
Company
Company
Name
Street
Address
City
State
Zip
Code
1.6
Company
Contact
Identification
Reporting
Company
Contact
Person
Phone
Number
Fax
Number
E­
mail
Address
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,
8th
Floor
Washington,
DC
20005
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.

Pending
EPA
ICR
NUMBER
2014.03,
Revised
4/
06
OMB
Control
Number:
2060­
0498
Pending
Expiration
Date:
6/
30/
06
U.
S.
Environmental
Protection
Agency
STRATOSPHERIC
OZONE
PROTECTION
PROGRAM
CLASS
II
CONTROLLED
SUBSTANCE
EXPORTER
QUARTERLY
REPORT
(
Sec
82.24)

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
Quantity
of
Commodity
Exported
(
kg)
If
Export
is
not
a
Blend:
HCFC
Quantity
(
kg)

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

HCFC
in
Blend
Quantity
(
kg)
HCFC
in
Blend
Quantity
(
kg)
HCFC
in
Blend
Quantity
(
kg)

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

Select
One:
New
Used
Select
One:
Transformation
Destruction
Export
Production
Article
5
Produced
with
Production
Allowances/
Consumption
Allowances
Exporting
Vessel
on
which
export
was
shipped:
Exporter
EIN
from
Customs
Form
7525:

(
Complete
if
export
production
allowances
or
Article
5
allowances
is
selected
above)

TRANSACTION
#

Recipient
Company
Name
Street
Address
City
Country
Postal
Code
Article
5
Country
Company
Contact
Person
Phone
Number
Fax
Number
Quantity
of
Commodity
Exported
(
kg)
If
Export
is
not
a
Blend:
HCFC
Quantity
(
kg)

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

HCFC
in
Blend
Quantity
(
kg)
HCFC
in
Blend
Quantity
(
kg)
HCFC
in
Blend
Quantity
(
kg)

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

Select
One:
New
Used
Select
One:
Transformation
Destruction
Export
Production
Article
5
Produced
with
Production
Allowances/
Consumption
Allowances
Exporting
Vessel
on
which
export
was
shipped:
Exporter
EIN
from
Customs
Form
7525:

(
Complete
if
export
production
allowances
or
Article
5
allowances
is
selected
above)

Pending
EPA
ICR
NUMBER
2014.03,
Revised
4/
06
OMB
Control
Number:
2060­
0498
Pending
Expiration
Date:
6/
30/
06
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
3.2
Transaction
Summaries
Class
II
Substance
(
Commodity
Code)

(
Select
only
one
below)

HCFC­
22
(
2903.49.9010)
HCFC­
123
(
2903.49.0000)
HCFC­
124
(
2903.49.0000)
HCFC­
133
(
2903.49.0000)

HCFC­
141b
(
2903.49.0000)
HCFC­
142b
(
2903.49.0000)
HCFC­
225ca
(
2903.49.0000)
HCFC­
225cb
(
2903.49.0000)

HCFC
and
Commodity
Code
(
if
not
listed
above)

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

Pending
EPA
ICR
NUMBER
2014.03,
Revised
4/
06
