CHEMICAL CONTROL ORDER FOR OZONE DEPLETING SUBSTANCES (ODS)

ANNUAL REPORT FORM

For Dealers, Retailers and Re-sellers

Reporting Period _______________________

A. GENERAL INFORMATION

1. Name of Company: _______________________________________________________________

2. Registration Number: _______________________________________________________________
3. Business Address: _______________________________________________________________
_______________________________________________________________
4. Nature of Business:
Retailer/Resellers and Dealer with refilling Retailer/Resellers and dealer without refilling

5. Point Person: _______________________________________________________________

Position/Designation: ____________________ Email Address: ____________________

Telephone Number: ____________________ Facsimile Number: ____________________

B. MANAGEMENT INFORMATION

Storage

Location: ____________________________________________________________________

Size (in m2): ________________ Storage capacity: _________________________

Description of Storage Procedure: ___________________________________________

___________________________________________
___________________________________________

Inspection and Monitoring Frequency: _____________________

Problems Encountered: __________________________________________________

__________________________________________________
__________________________________________________

Actions Taken: __________________________________________________

__________________________________________________
__________________________________________________
 Personnel involved in management of ODS

Name Position Responsibility Qualification/Training Employment Status*

* Permanent or contractual

C. SUMMARY OF TRANSACTIONS

Brand/Trade/Commercial Name: ________________________________________________________________

Importer/Distributor: ________________________________________________________________
Actual Arrival Quantity (in kgs): ________________________________________________________________
Total Quantity Distributed (in kgs): ________________________________________________________________

Quantity
Name of Person Intended Date of
Registration Address Contact No. Distributed Invoice No.
or Company User/Sector Sale
Number (kgs)

* per chemical

D. Participation in the Reclamation Facility (RF)

Name of Person or Company Assisted/Endorsed to the

Quantity Date
RF ODS/Other Chemicals

Prepared by: Approved by:

Signature: _______________________ Signature: __________________________

Name: _______________________ Name: __________________________
Position: _______________________ Position: __________________________
Date Accomplished: _______________________