  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 

importer 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 # 5900-200, 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 

importer quarterly report

(Sec 82.24)

SECTION 2    TRANSACTION RECORDS                              (Reproduce
Additional Sheets as Needed)

2.1 Company Name	  FORMTEXT        			

2.2 Transaction Summaries	





TRANSACTION #	  FORMTEXT        			

Source Country    FORMTEXT        	Customs Entry Summary
Number    FORMTEXT        

Port of Entry into the U.S.   FORMTEXT        	Date of Import
(mm/dd/yy)    FORMTEXT        

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

If Import 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; Date of
Non-objection Notice:    FORMTEXT        	  FORMCHECKBOX  
Heels (Report Annual Imports in 4th Quarter Only)

If New: 	  FORMCHECKBOX   HCFC-141b Exemption	  FORMCHECKBOX  
Transformation  	  FORMCHECKBOX   Destruction	  FORMCHECKBOX   None

If Used:	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction	 
FORMCHECKBOX   Other; Please Specify   FORMTEXT        

If Heels:	  FORMCHECKBOX   Included in Future Shipment	  FORMCHECKBOX  
Transformation	  FORMCHECKBOX   Destruction	  FORMCHECKBOX  
Non-Emissive Use



TRANSACTION #	  FORMTEXT        			

Source Country    FORMTEXT        	Customs Entry Summary
Number    FORMTEXT        

Port of Entry into the U.S.   FORMTEXT        	Date of Import
(mm/dd/yy)    FORMTEXT        

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

If Import 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; Date of
Non-objection Notice:    FORMTEXT        	  FORMCHECKBOX  
Heels (Report Annual Imports in 4th Quarter Only)

If New: 	  FORMCHECKBOX   HCFC-141b Exemption	  FORMCHECKBOX  
Transformation  	  FORMCHECKBOX   Destruction	  FORMCHECKBOX   None
Apply

If Used:	  FORMCHECKBOX   Transformation	  FORMCHECKBOX   Destruction	 
FORMCHECKBOX   Other; Please Specify   FORMTEXT        

If Heels:	  FORMCHECKBOX   Included in Future Shipment	  FORMCHECKBOX  
Transformation	  FORMCHECKBOX   Destruction	  FORMCHECKBOX  
Non-Emissive Use

EPA Form # 5900-200, 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 

importer quarterly report

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3.2 Company Import Totals



	A	B	C	D	E	F	G	H	I	J

Chemical Name

(Commodity Code)	Gross Imports (kg)	In-House Transformation (kg)
Second-Party Transformation (kg)	In-House Destruction (kg)	Second-Party
Destruction (kg)	HCFC-141b Exemption (kg)	Net Imports 

(B-C-D-E-F-G=H)

(kg)	Total “Used” Imports (kg)	Total  “Heels” 

(4th Quarter Reporting Only) (kg)

HCFC-22

(2903.71.0000)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC-123

(2903.72.0020)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC-124

(2903.79.9030)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC-141b

(2903.73.0000)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC-142b

(2903.74.0000)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC-225ca

(2903.75.0000)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC-225cb

(2903.75.0000)	  FORMTEXT        	  FORMTEXT        
  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      

HCFC and Commodity Code (if not listed above)   FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

  FORMTEXT        	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        	  FORMTEXT 
      	  FORMTEXT        

EPA Form # 5900-200, 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 

importer quarterly report

(Sec 82.24)

SECTION 4    ALLOWANCE EXPENDITURE TOTALS

4.1 Company Name	    FORMTEXT        

4.2 Allowance Balance Summary

	A	B

Chemical

Name	Total consumption allowances for year to date (as of the end of the
quarter) that were:

	Expended	Unexpended

HCFC-22	  FORMTEXT        	  FORMTEXT        

HCFC-142b	  FORMTEXT        	  FORMTEXT        

HCFC-123	  FORMTEXT        	  FORMTEXT        

HCFC-124	  FORMTEXT        	  FORMTEXT        

HCFC-225ca	  FORMTEXT        	  FORMTEXT        

HCFC-225cb	  FORMTEXT        	  FORMTEXT        

4.3 Name(s) of HCFC-141b Exemption Allowance Holder(s) from whom Orders
were Received and Associated Quantity (kg) of HCFC-141b Requested and
Imported

Company Name:    FORMTEXT          	HCFC-141b Requested and
Imported (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Imported (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Imported (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Imported (kg):   FORMTEXT         

Company Name:    FORMTEXT          	HCFC-141b Requested and
Imported (kg):   FORMTEXT         

EPA Form # 5900-200, Revised 10/12

