  U.S. Environmental Protection Agency
    stratospheric ozone protection program
                         class i controlled substance
                  laboratory certification report (Sec 82.13)
SECTION 1
LABORATORY IDENTIFICATION
1.1 Date of Submission
          
1.2  Original Submittal   Re-submittal
1.3  Number of Class I Substances Reported
          
1.4 Number of Pages Submitted
          

1.5 Laboratory Information
Laboratory Name            
Street Address           

City           
State           
Zip Code           
1.6 Laboratory Contact Identification
 Reporting Laboratory Contact Person           
Phone Number           
Fax Number           
E-mail Address           
1.7 Signature of Reporting Laboratory Representative
I certify that the quantities of controlled substances listed in this form are purchased solely for use in laboratory applications and will not be resold or used in manufacturing.
    
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:
The Company from Whom the 
Class I Substances Were Purchased

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 2.1 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.

  U.S. Environmental Protection Agency 

     stratospheric ozone protection program
                         class i controlled substance
                  laboratory certification report (Sec 82.13)
SECTION 2
SUBSTANCE IDENTIFICATION AND USE
(Reproduce Additional Sheets as Needed)
2.1 Lab Name
          
2.2 Class I Substance   (Select only one below)
                                                                         CFC-11
                                       
                                                                         CFC-12
                                       
                                                                         CFC-13
                                       
                                                                        CFC-111
                                       
                                                                        CFC-112
                                       
                                                                               
                                                                               
                                                                        CFC-113
                                       
                                                                        CFC-114
                                       
                                                                        CFC-115
                                       
                                                     Other CFC (please specify)
                                       
                                                                               
          
                                                                               
                                                                               
                                                          HBFC (please specify)
                                       
                                                                               
          
                                                         Halon (please specify)
                                       
                                                                               
          
                                                                               
                                                                               
                                                           Carbon Tetrachloride
                                       
                                                              Methyl Chloroform
                                       
                                                                          CBM  
                                       
                                                                 Methyl Bromide
                                       
                                                                               

2.3 Amount of Class I Substance (kg)
          
2.4 Laboratory Applications (Select as many as apply and indicate percent use)
 A. Research and Development
     Reaction Solvent or Reaction Feedstock.......................................................
B. Analytical Uses and Regulated Applications
       Reference
         Chemical.............................................................................................
       Toxicant...............................................................................................
          Product................................................................................................
       Extraction 
      Pesticide and Heavy Metal Detection.................................................	G ____%
     Product................................................................................................
     Color & Food Additive Detection.........................................................
       Diluent
         Zinc, Copper, Cadmium Detection in Plants and Food.......................
         Microchemical Methods to Determine Molecular Weight of Oxygen...
         Measuring Drug Purity and Residual Information................................
     Sterilization of Lab Equipment............................................................
       Carrier (Inert)
         Forensic Methods................................................................................
         Titration...............................................................................................
         Analytical Equipment...........................................................................
       Tracer
     Sanitary Engineering...........................................................................
       Miscellaneous (Including Testing)
         Ingredient in Material for Testing........................................................
          Separation Media................................................................................
 C.  Miscellaneous
      Laboratory Method Development.............................................
      Sample Preparation Using Solvent...........................................
         

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SECTION 3
 SUPPLIER IDENTIFICATION
 3.1 Supplier Name
           
 

