OMB
#
2060­
0256
Expiration
Date:
07/
31/
2006
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
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.
BOTH
THE
INSTRUCTIONS
AND
MAILING
ADDRESSES
CAN
BE
FOUND
ON
THE
REVERSE
SIDE
OF
THIS
FORM.

PART
1:
ESTABLISHMENT
INFORMATION
Name
of
Establishment
Street
(
Area
Code)
Telephone
Number
City
State
Zip
Code
Number
of
Service
Vehicles
Based
at
Establishment
County
PART
2:
REGULATORY
CLASSIFICATION
Identify
the
type
of
work
performed
by
the
establishment.
Check
all
boxes
that
apply.


Type
A
­
Service
small
appliances

Type
B
­
Service
refrigeration
or
air­
conditioning
equipment
other
that
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
Name
of
Device(
s)
Manufacturer
Model
Number
Year
Serial
Number
(
if
any)
Check
Box
if
Self­
Contained
1.
G
2.
G
3.
G
4.
G
5.
G
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
regulations,
and
that
the
information
gives
is
true
and
correct.

Signature
of
Owner/
Responsible
Officer
Date
Name
(
Please
Print)
Title
The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
one
(
1)
hour
per
response.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
i
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.
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
SEA;
JFK
Federal
Building;
One
Congress
Street,
Suite
1100;
Boston,
MA
02114­
2023
Part
2:
Check
the
appropriate
boxes
for
the
type
of
work
performed
by
technicians
who
are
employees
of
the
establishment.
The
term
"
small
appliance"
refers
to
any
of
the
following
products
tat
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.
New
York,
New
Jersey,
Puerto
Rico,
Virgin
Islands
CAA
608
Enforcement
Contact:
EPA
Region
II;
Mail
Code
2DECA­
AC;
290
Broadway;
New
York,
NY
10007­
1866
Delaware,
District
of
Columbia,
Maryland,
Pennsylvania,
Virginia,
West
Virginia
CAA
608
Enforcement
Contact:
EPA
Region
III­
Wheeling
Office;
Mail
Code
3AP12;
303
Methodist
Building;
11th
and
Chapline
Streets;
Wheeling,
WV
26003
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
that
seven
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
te
refrigerant
from
an
appliance
without
the
assistance
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
2,
then
the
first
device
listed
in
Part
#
must
be
a
selfcontained
device
and
identifies
as
such
by
checking
the
box
in
the
last
column
on
the
right.
If
any
of
the
devices
are
homemade,
they
should
be
identified
by
writing
"
homemade"
in
the
column
provided
for
listing
the
name
of
the
device
manufacturer.
Type
A
or
Type
B
establishments
can
use
homemade
devices
manufactured
before
November
15,
1993.
Type
C
or
Type
D
establishments
can
use
homemade
manufactured
anytime.
If,
however,
a
Type
C
or
Type
D
establishment
is
using
homemade
equipment
manufactured
after
November
15,
1993,
then
it
must
not
use
these
devices
for
service
jobs.
Alabama,
Florida,
Georgia,
Kentucky,
Mississippi,
North
Carolina,
South
Carolina,
Tennessee
CAA
608
Enforcement
Contact:
EPA
Region
IV;
Mail
Code
APT­
AE;
61
Forsyth
Street,
SW;
Atlanta,
GA
30303­
8960
Illinois,
Indiana,
Michigan,
Minnesota,
Ohio,
Wisconsin
CAA
608
Enforcement
Contact:
EPA
Region
V;
Mail
Code
AE­
17J;
77
West
Jackson
Blvd.;
Chicago,
IL
60604
Arkansas,
Louisiana,
New
Mexico,
Oklahoma,
Texas
CAA
608
Enforcement
Contact:
EPA
Region
VI;
Mail
Code
6EN­
AA;
1445
Ross
Ave.,
Suite
1200;
Dallas,
TX
75202
Iowa,
Kansas,
Missouri,
Nebraska
CAA
608
Enforcement
Contact:
EPA
Region
VII;
Mail
Code
APCOARTD;
901
North
Fifth
Street;
Kansas
City,
KS
66101
Colorado,
Montana,
North
Dakota,
South
Dakota,
Utah,
Wyoming
CAA
608
Enforcement
Contact:
EPA
Region
VIII;
Mail
Code
8ENF­
T;
999
18th
Street,
Suite
500;
Denver,
CO
80202
ii
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
regulations,
and
that
the
information
provided
is
true
and
accurate.
American
Samoa,
Arizona,
California,
Guam,
Hawaii,
Nevada
CAA
608
Enforcement
Contact:
EPA
Region
IX;
Mail
Code
AIR­
5;
75
Hawthorne
Street;
San
Francisco,
CA
94105
Alaska,
Idaho,
Oregon,
Washington
CAA
608
Enforcement
Contact:
EPA
Region
X;
Mail
Code
OAQ­
107;
1200
Sixth
Ave.;
Seattle,
WA
98101
iii
PUBLIC
BURDEN
OMB
#
2060­
0256
Expiration
Date:
07/
31/
2006
The
purpose
and
need
of
this
renewed
collection
request
is
to
facilitate
compliance
with
and
enforcement
of
Section
608
of
the
Act
by
reducing
emissions
of
class
I
and
class
II
ozone­
depleting
refrigerants
to
the
lowest
achievable
level
during
the
service,
maintenance,
repair,
and
disposal
of
appliances.
EPA
has
used
and
will
continue
to
use
these
records
and
reports
to
ensure
that
refrigerant
releases
are
minimized
during
the
recovery
and
recycling
of
ozone­
depleting
refrigerants
during
the
service,
maintenance,
repair,
and
disposal
of
appliances.
Collection
of
this
information
is
mandated
by
EPA
regulations,
in
accordance
with
40
CFR
82.162.
This
information
is
not
shared
with
parties
outside
of
the
Federal
government.
EPA's
confidentiality
regulations
(
40
CFR
2.201
et
seq.)
assure
computer
data
security,
disclosure
prevention,
proper
handling,
proper
storage,
and
proper
disposal
of
the
submitted
information.

The
public
reporting
and
recordkeeping
burden
for
this
collection
of
information
is
estimated
to
average
one
(
1)
hour
per
response
per
respondent
annually.
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.

To
comment
on
the
Agency's
need
for
this
information,
the
accuracy
of
the
provided
burden
estimates,
and
any
suggested
methods
for
minimizing
respondent
burden,
including
the
use
of
automated
collection
techniques,
EPA
has
established
a
public
docket
for
this
ICR
under
Docket
ID
No.
OAR­
2003­
0018,
which
is
available
for
public
viewing
at
the
Air
and
Radiation
Docket
and
Information
Center
in
the
EPA
Docket
Center
(
EPA/
DC),
EPA
West,
Room
B102,
1301
Constitution
Ave.,
NW,
Washington,
DC.
The
EPA
Docket
Center
Public
Reading
Room
is
open
from
8:
30
a.
m.
to
4:
30
p.
m.,
Monday
through
Friday,
excluding
legal
holidays.
The
telephone
number
for
the
Reading
Room
is
(
202)
566­
1744,
and
the
telephone
number
for
the
OAR
Docket
is
(
202)
566­
1742.
An
electronic
version
of
the
public
docket
is
available
through
EPA
Dockets
(
EDOCKET)
at
http://
www.
epa.
gov/
edocket.
Use
EDOCKET
to
submit
or
view
public
comments,
access
the
index
listing
of
the
contents
of
the
public
docket,
and
to
access
those
documents
in
the
public
docket
that
are
available
electronically.
Once
in
the
system,
select
"
search,"
then
key
in
the
docket
ID
number
identified
above.
Also,
you
can
send
comments
to
the
Office
of
Information
and
Regulatory
Affairs,
Office
of
Management
and
Budget,
725
17th
Street,
NW,
Washington,
DC
20503,
Attention:
Desk
Office
for
EPA.
Please
include
the
EPA
Docket
ID
No.
(
OAR­
2003­
0018)
and
OMB
control
number
(
2060­
0256)
in
any
correspondence.
