5/17/2012
Ozone Depleting Substances Compliance Offset Project
Listing Information
Instructions: This form should be completed in order to submit an Ozone Depleting
Substances (ODS) Compliance Offset Project pursuant to Section 95975(e) of the California
cap-and-trade regulation.
Please complete all fields as thoroughly as possible. If the project in question is still in the
planning/development phase, all fields must be completed using best available data and
estimates based on the proposed project design. This is an interactive Word form. Upon
completion please save this form as a PDF prior to uploading it to the Reserve. All fields must
be completed.
1.
Offset Project name (as it appears in the Reserve software):
a. Reserve project ID (numerical, as it appears in the Reserve software):
CAR
2.
Offset Project Operator or Authorized Project Designee:
3.
Technical consultants:
4.
Other parties with a material interest:
5.
Date of form completion:
6.
Form completed by (name, organization):
7.
Offset project description (please provide one to two paragraphs):
8.
List all points of origin by US state for ODS sourced for this project:
9.
Please select the ODS sources that will be destroyed under this project (check all that
apply):
Refrigerants
CFC-11
CFC-12
CFC-13
CFC-113
CFC-114
CFC-115
ODS blowing agent in intact building foam
CFC-11
CFC-12
HCFC-22
HCFC-141b
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Concentrated ODS blowing agent from appliance foam
CFC-11
CFC-12
HCFC-22
HCFC-141b
10.
Name of destruction facility:
11.
Address of destruction facility:
12.
Is the destruction facility a RCRA-permitted hazardous waste combustor (HWC)?
Yes
No
13.
If the destruction facility is not a RCRA-permitted HWC, has it met the TEAP
requirements for ODS destruction re-produced in the protocol?
Yes
No
14.
Offset project commencement date:
15.
Reporting period (MM/DD/YYYY):
to
16.
Have any GHG reductions associated with the offset project ever been registered with or
claimed by another registry or program, or sold to a third party prior to our listing?
No
Yes Registry/Program:
Reporting Period:
Vintage:
Credits Issued:
17.
Is this offset project being implemented and conducted as the result of any law, statute,
regulation, court order, or other legally binding mandate?
No
Yes
If yes, please explain:
18.
Has an Offset Project Data report been developed?
If not, what date will the plan be in place?
Yes
No
19.
Has the project-specific recovery efficiency been determined (for appliance foam
projects only)?
Yes
If yes, what is the factor?
No
If not, when will
this factor be established?
20.
Was, or will, any of the destroyed ODS be sourced from the U.S. government?
No
Yes If yes, how much?
21.
Was, or will, any of the destroyed ODS be considered hazardous waste under U.S.,
state, or local law?
No
Yes If yes, how much and explain?
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5/17/2012
ATTESTATIONS
“I certify under penalty of perjury under the laws of the State of California the GHG
reductions and/or GHG removal enhancements for Insert Project Name from Date to Date will
be measured in accordance with the Compliance Offset Protocol Ozone Depleting Substances
Projects and all information required to be submitted to ARB is true, accurate, and complete.”
“I understand I am voluntarily participating in the California Greenhouse Gas Cap-and-Trade
Program under title 17, article 5, and by doing so, I am now subject to all regulatory
requirements and enforcement mechanisms of this program and subject myself to the
jurisdiction of California as the exclusive venue to resolve any and all disputes arising from the
enforcement of provisions in this article.”
“I understand that the offset project activity and implementation of the offset project must be
in accordance with all applicable local, regional, and national environmental and health and
safety laws that apply to the offset project location. I understand that offset projects are not
eligible to receive ARB or registry offset credits for GHG reductions and GHG removal
enhancements that are not in compliance with the requirements of the cap-and-trade program.”
__________________________________________
Signature
Offset Project Operator/Authorized Project Name:
Title:
Organization:
:
Disclaimer: Please note that the Climate Action Reserve is not yet an approved Offset Registry
pursuant to section 95986 of the California cap-and-trade regulation. This form is intended to
help compliance projects initiate their listing process to expedite future project verification and
registration. Any guidance provided pertaining to this form or the regulation is not official
guidance and is not binding. Furthermore, submission of this form does not constitute
completion of the listing process pursuant to Section 95975, nor does it guarantee that (1) the
project or this form will satisfy the listing requirements of the California Air Resources Board’s
program, or (2) the California Air Resources Board will authorize the applicant’s participation in
the program per Section 95830.
End of form
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