  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

second-party transformation

      	1.2  Year To Which This Report Applies	  FORMTEXT 
      

1.3    FORMCHECKBOX  Original Submittal    FORMCHECKBOX   Re-submittal

	1.4 Have you submitted a transformation verification to the producer or
importer (per Sec 82.24)?	  FORMCHECKBOX   Yes   FORMCHECKBOX   No	Date
Submitted:	  FORMTEXT        

1.5 Company Information

Company Name    FORMTEXT        



Street Address    FORMTEXT        



City    FORMTEXT        	State    FORMTEXT        
Zip Code    FORMTEXT        

1.6 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 # 5900-204, Revised 9/12    SEQ CHAPTER \h \r 1 	OMB Control
Number: 2060-0498

	Expiration Date: TBD

  U.S. Environmental Protection Agency

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         stratospheric ozone protection program

	class ii controlled substance

second-party transformation

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  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

EPA Form # 5900-204, Revised 9/12  

