	OMB Control Number: 2060-0498

	Expiration Date: TBD

  U.S. Environmental Protection Agency	

               stratospheric ozone protection program	class ii
controlled substance

exporter quarterly report

      

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 # 5900-199, Revised 10/12    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

exporter quarterly report

      			

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        

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

If Export Is Not a Blend:    	HCFC:   FORMTEXT                
    	Quantity (kg):    FORMTEXT        

If Export Is a Blend:	Name of Blend:   FORMTEXT               
                                                                        
	Quantity (kg):    FORMTEXT        

HCFC in Blend:   FORMTEXT        

Quantity (kg):   FORMTEXT          	HCFC in Blend:    FORMTEXT
       

Quantity (kg):   FORMTEXT          	HCFC in Blend:    FORMTEXT
       

Quantity (kg):   FORMTEXT          

Transaction Type:	  FORMCHECKBOX   New	  FORMCHECKBOX   Used

	If New: 	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction	 
FORMCHECKBOX   Produced or Imported with Production and/or Consumption
Allowances  

	  FORMCHECKBOX   Produced with Article 5 Allowances	  FORMCHECKBOX  
Produced or Imported without Production and/or Consumption Allowances

If Used:	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction	 
FORMCHECKBOX   Other



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Recipient Company Name    FORMTEXT        

Street Address    FORMTEXT        

City    FORMTEXT        	Country    FORMTEXT        
Postal Code    FORMTEXT        

Company Contact Person    FORMTEXT        	Phone Number   
FORMTEXT        	Fax Number    FORMTEXT        

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

If Export Is Not a Blend:    	HCFC:   FORMTEXT                
    	Quantity (kg):    FORMTEXT        

If Export Is a Blend:	Name of Blend:   FORMTEXT               
                                                                        
	Quantity (kg):    FORMTEXT        

HCFC in Blend:   FORMTEXT        

Quantity (kg):   FORMTEXT          	HCFC in Blend:    FORMTEXT
       

Quantity (kg):   FORMTEXT          	HCFC in Blend:    FORMTEXT
       

Quantity (kg):   FORMTEXT          

Transaction Type:	  FORMCHECKBOX   New	  FORMCHECKBOX   Used

	If New: 	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction	 
FORMCHECKBOX   Produced or Imported with Production and/or Consumption
Allowances  

	  FORMCHECKBOX   Produced with Article 5 Allowances	  FORMCHECKBOX  
Produced or Imported without Production and/or Consumption Allowances

If Used:	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction	 
FORMCHECKBOX   Other

EPA Form # 5900-199, Revised 10/12	  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

exporter quarterly report

(Sec 82.24)

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

3.1 Company Name	  FORMTEXT        			

3.2 Transaction Summaries	



Class II Substance

(Commodity Code)

(Select only one below)

  FORMCHECKBOX    HCFC-22

(2903.71.0000)	  FORMCHECKBOX    HCFC-123

(2903.72.0020)	  FORMCHECKBOX    HCFC-124

(2903.79.9030)	  FORMCHECKBOX    HCFC-142b

(2903.74.0000)	  FORMCHECKBOX    HCFC-225ca

(2903.75.0000)	  FORMCHECKBOX    HCFC-225cb

(2903.75.0000)

HCFC and Commodity Code (if not listed above)	  FORMTEXT 
      



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

  FORMTEXT        	  FORMTEXT        

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  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        

EPA Form # 5900-199, Revised 10/12

