EPA_EQUIPMENT

Click here: Commercial HVAC Sec 608 Automotive MVAC Sec 609

OMB # 2060-256
Expiration Date: 5/96

The United States Environmental Protection Agency (EPA)
Refrigerant Recovery or Recycling Device
Acquisition Certification Form

EPA regulations require establishments that service or dispose of refrigeration or air conditioning equipment to certify by august 12, 1993 that they have acquired recovery or recycling devices that meet EPA standards for such devices. To certify that you have acquired equipment, please complete this form according to the instructions and mail it to the appropriate EPA Regional Office.

PART 1: ESTABLISHMENT INFORMATION

Name of establishment
Street

(Area Code) Telephone Number
City

Number of Service Vehicles Based at ESTABLISHMENT
County

PART 2: REGULATORY CLASSIFICATION

Identify the type of work performed by the ESTABLISHMENT. Check all that apply.
______ Type A - Service small appliances
______ Type B - Service refrigeration or air conditioning equipment other than small appliances.
______ Type C - Dispose of small appliances.
______ Type D - Dispose of refrigeration or air conditioning equipment other than small appliances.

PART 3: DEVICE IDENTIFICATION

Qty Name of Device(s) Manufacturer Model Number Year Serial Number (If any) Check box if
Self-Contained

. Refrigerant Recovery Technology Inc./Timco Label
(multiple listing) 3000, 3000R, TC2,
RetroUSA 97-99 . ü

. Refrigerant Recovery Technology Inc./Timco Label
(multiple listing) 6000, 6000h 95-98 . ü

. Refrigerant Recovery Technology Inc./Timco Label
(multiple listing) 4000, RetroUSA 95-99 . ü

. . . . . .

. . . . . .

PART 4: CERTIFICATION SIGNATURE

I certify that the establishment in Part 1 has acquired the refrigerant recovery or recycling device(s) listed in
Part 2, that the establishment is complying with Section 608 regulation, and that information given is true and correct.

Signature of Owner/Responsible Officer

Date

Name (Please Print)

Title

Public responding burden for this collection of information is estimated to vary from 20 minutes to 60 minutes per response with an average of 40 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. Send comments regarding ONLY the burden estimates or any other aspects of this collection of information, including suggestions for reducing this burden to Chief, Information Policy Branch: EPA; 401 M St. S. W. (PM-223Y); Washington, DC. 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503, market "Attention: Desk Officer of EPA" DO NOT SEND THIS FORM TO THE ABOVE ADDRESSES. ONLY SEND COMMENTS TO THESE ADDRESSES

Instructions

PART 1: Please provide the name, address, and telephone number of the establishment where the refrigerant recovery or recycling device(s) is (are) located. Please complete one form for each location. State the number of vehicles based at this location that are used to transport technicians and equipment to and from service sites.

PART 2: Check the appropriate boxes for the type of work performed by technicians who are employees of the establishment. The term "small appliances" refers to any of the following products that are fully manufactured, charged, and hermetically sealed in a factory with five pounds or less of refrigerant: refrigerators and freezers designed for home use, room air conditioners (including window air conditioners and packaged terminal air conditioners), packaged terminal heat pumps, dehumidifiers, under-the-counter ice makers, vending machines, and drinking water coolers.

PART 3: For each recovery or recycling device acquired, please list the name of the manufacturer of the device, and (if applicable) its model number and serial number.
If more than 7 devices have been acquired , please fill out an additional form and attach it to this one. Recovery devices that are self-contained should be listed first and should be identified by checking the box in the last column on the right. Self-contained recovery equipment means refrigerant recovery or recycling equipment that is capable of removing the refrigerant from an appliance without the assistant of components contained in the appliance. On the other hand, system dependent recovery equipment means refrigerant recovery equipment that requires the assistance of components contained in an appliance to remove the refrigerant from the appliance.
If the establishment has been listed as Type B and/or Type D in Part , then the first device listed in Part 3 must be a self-contained device and identified as such by checking the box in the last column on the right.
If any device is homemade, they should be identified by writing "homemade" in the column provided for listing for listing the name of the device manufacturer. Type A or Type B establishments can use homemade devices manufactured before November 15, 199. Type C or Type D establishments can use homemade devices manufactured anytime. If however a Type C or Type D establishments is using homemade equipment manufactured after November 15, 1993, then it must not use these devices for service jobs.

PART 4: This form must be signed by either the owner of the establishment or another responsible officer. The person who signs is certifying that the establishment has acquired the equipment, that the establishment is complying with Section 608 regulation, and that the information provided is true and correct.

EPA Regional Offices: Send your form to the EPA office listed under the state or territory in which the establishment is located.

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont	CAA 608 Enforcement Contact: EPA Region I Mail code APC, JFK Federal Building, One Congress Street, Boston, MA 02203
New York, New Jersey, Puerto Rico, Virgin Islands	CAA 608 Enforcement Contact: EPA Region II Jacob K. Javitas Federal Building, Room 5000,26 Federal Plaza, New York, NY 10278
Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia.	CAA 608 Enforcement Contact: EPA Region III, Mail Code 3AT21, 841 Chestnut Building, Philadelphia, PA 19107
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee	CAA 608 Enforcement Contact: EPA Region IV, Mail Code APT-AE, 345 courtland Street, NE, Atlanta, GA 30365
Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin	CAA 608 Enforcement Contact: EPA Region V, Mail Code AT18J, 77 W. Jackson Blvd., Chicago, IL 60604
Arkansas, Louisiana, New Mexico, Oklahoma, Texas	CAA 608 Enforcement Contact: EPA Region VI Mail Code 6T-EC. First Interstate Tower at Fountain Place, 1445 Ross Ave., Suite 1200 Dallas TX 75202
Iowa, Kansas, Missouri, Nebraska	CAA 608 Enforcement Contact: EPA Region VII, Mail Code ARTX/ARBR, 726 Minnesota Ave., Kansas City, KS 66101
Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming	CAA 608 Enforcement Contact: EPA Region VIII, Mail Code 8AT-AP, 99918th Street, Suite 500 Denver, CO 80202
American Samoa, Arizona, California, Guam, Hawaii, Nevada	CAA 608 Enforcement Contact: EPA Region IX, Mail Code A-3, 75 Hawthorne Street, San Francisco, CA 94105
Alaska, Idaho, Oregon, Washington	CAA 608 Enforcement Contact: EPA Region X, Mail Code AT- 082, 1200 Sixth Ave. Seattle, WA 98101

This form was developed by the U. S. EPA and reproduce courtesy of TimcoUSA. timco@tipages.com