  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

request for additional class ii 

consumption allowances

      	1.2  Number of Transactions Reported	  FORMTEXT 
      

1.3  Number of Pages Submitted	  FORMTEXT        	1.4   
FORMCHECKBOX  Original Submittal    FORMCHECKBOX   Re-submittal

NOTE: ATTACH ALL BILLS OF LADING AND INVOICES SHOWING NET QUANTITY
SHIPPED AND DOCUMENTING THE SALE

1.5 Exporting Company

	Company Name   FORMTEXT        



Street Address    FORMTEXT        

                              

City    FORMTEXT        	State    FORMTEXT        

           	Zip Code     FORMTEXT        

Exporter EIN from Customs Form 7525    FORMTEXT        

1.6 Company Contact Identification

Reporting Company Contact Person

  FORMTEXT        

	Phone Number

  FORMTEXT        	Fax Number

  FORMTEXT        

E-mail Address    FORMTEXT        



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   FORMTEXT         

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 # 5900-201, Revised 9/12    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

request for additional class ii

consumption allowances

(Sec 82.20)

SECTION 2    TRANSACTION RECORDS

      			

2.2 Transaction Summaries	



TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        

	Street Address    FORMTEXT        



City   FORMTEXT        	Country   FORMTEXT        
Postal Code   FORMTEXT        

Company Contact Person   FORMTEXT        	Phone Number  
FORMTEXT        	Fax Number   FORMTEXT        

Quantity of Commodity Exported (kg)   FORMTEXT         

HCFC Chemical Exported   FORMTEXT        	Quantity of HCFC
Exported (kg)   FORMTEXT        

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

Select One: 	(a) Company that produced the HCFC (expending production
and consumption allowances):    FORMTEXT        	Date
Purchased  

  FORMTEXT        

	(b) Company that imported HCFC (expending consumption allowances), AND
country imported from:

    FORMTEXT        



	TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        

	Street Address    FORMTEXT        

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؀  FORMTEXT        	Quantity of HCFC Exported (kg)   FORMTEXT
       

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

Select One:	(a) Company that produced the HCFC (expending production and
consumption allowances):    FORMTEXT        	Date Purchased   
FORMTEXT        

 

	(b) Company that imported HCFC (expending consumption allowances), AND
country imported from:

    FORMTEXT        



	TRANSACTION #	  FORMTEXT        			

Recipient Company Name    FORMTEXT        

	Street Address    FORMTEXT        



City   FORMTEXT        	Country   FORMTEXT        
Postal Code   FORMTEXT        

Company Contact Person   FORMTEXT        	Phone Number  
FORMTEXT        	Fax Number   FORMTEXT        

Quantity of Commodity Exported (kg)   FORMTEXT        

HCFC Chemical Exported   FORMTEXT        	Quantity of HCFC
Exported (kg)   FORMTEXT        

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

Select One:	(a) Company that produced the HCFC (expending production and
consumption allowances):    FORMTEXT        	Date Purchased   
FORMTEXT        

 

	(b) Company that imported HCFC (expending consumption allowances), AND
country imported from:

    FORMTEXT        

	EPA Form # 5900-201, Revised 9/12  		

OMB Control Number: 2060-0498

		Expiration Date: TBD  SEQ CHAPTER \h \r 1 

     U.S. Environmental Protection Agency

       stratospheric ozone protection program	class ii controlled
substance

request for additional class ii

consumption allowances

(Sec 82.20)

SECTION 3    COMPANY EXPORT TOTALS

3.1 Company Name	  FORMTEXT        

3.2 Company Request Summary	



A	B

Chemical Name 

(Commodity Code)	Total Consumption Allowances Requested (kg)

HCFC-22 

(2903.71.0000)	  FORMTEXT        

HCFC-142b

(2903.74.0000)	  FORMTEXT        

HCFC-123

(2903.72.0020)	  FORMTEXT        

HCFC-124 

(2903.79.9030)	  FORMTEXT        

HCFC-225ca

(2903.75.0000)	  FORMTEXT        

HCFC-225cb

(2903.75.0000)	  FORMTEXT        

Please note: This form must be accompanied by a written statement from
the producer that the class II controlled substances were produced with
expended allowances or a written statement from the importer that the
class II controlled substances were imported with expended allowances.

EPA Form # 5900-201, Revised 9/12  

