
                       ENVIRONMENTAL PROTECTION AGENCY 
                   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






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 	

	







      
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 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.

      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 self-contained 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.
      
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
     
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
     
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
     
Iowa, Kansas, Missouri, Nebraska

     CAA 608 Enforcement Contact:  EPA Region VII; Mail Code APCOARTD; 901 North Fifth Street; Kansas City, KS 66101


Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

     CAA 608 Enforcement Contact: EPA Region III-Wheeling Office; Mail Code 3AP12; 303 Methodist Building; 11[th] and Chapline Streets; Wheeling, WV 26003
     
Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

     CAA 608 Enforcement Contact:  EPA Region VIII; Mail Code 8ENF-T; 999 18[th] Street, Suite 500; Denver, CO 80202
     
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 
     
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 
     
Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

     CAA 608 Enforcement Contact:  EPA Region V; Mail Code AE-17J; 77 West Jackson Blvd.; Chicago, IL 60604
     
Alaska, Idaho, Oregon, Washington

     CAA 608 Enforcement Contact: EPA Region X; Mail Code OAQ-107; 1200 Sixth Ave.; Seattle, WA 98101 
     







PUBLIC BURDEN


     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. 

