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

SECTION
1
COMPANY
IDENTIFICATION
1.1
Date
of
Submission
1.2
Year
To
Which
This
Report
Applies
1.3
Have
you
submitted
a
one­
time
destruction
report
to
EPA
(
per
Sec
82.24)?
Yes
No
Date
Submitted:

1.4
Have
you
submitted
a
destruction
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
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
SECOND­
PARTY
DESTRUCTION
ANNUAL
REPORT
(
Sec
82.24)

SECTION
2
DESTRUCTION
SUMMARY
2.1
Company
Name
2.2
Transformation
Totals
A
B
Chemical
Name
Quantity
Destroyed
(
kg)

HCFC­
22
HCFC­
123
HCFC­
124
HCFC­
133
HCFC­
141b
HCFC­
142b
HCFC­
225ca
HCFC­
225cb
If
needed,
please
write
in
HCFCs
not
listed
above
Pending
EPA
ICR
NUMBER
2014.03,
Revised
4/
06
