           MVAC RECOVER, RECOVER/RECYCLE OR RECOVER/RECYCLE/RECHARGE
                         EQUIPMENT CERTIFICATION FORM
                                       
                                       
SEND THIS FORM TO THE EPA
REGIONAL OFFICE LISTED UNDER YOUR STATE OR TERRITORY IN WHICH THE ESTABLISHMENT IS
LOCATED.

MAILING ADDRESSES CAN BE
FOUND ON THE REVERSE SIDE OF THIS FORM.
1 ____________________________     NAME OF ESTABLISHMENT
   ____________________________
     STREET	
   ____________________________
     CITY, STATE, ZIP CODE
   ____________________________
     TELEPHONE NUMBER
2 ____________________________
     NAME OF EQUIPMENT MANUFACTURER & MODEL NUM
   ____________________________
     SERIAL NUMBER(S) YEAR

3 I certify that I have approved recover,
    recover/recycle, or recover/recycle/recharge
    equipment under Section 609 of the Clean Air
    Act. I certify that only properly trained and
    certified technicians operate the equipment and
    that the information given above is true and
    correct.
   ____________________________
     SIGNATURE OF OWNER/OPERATOR                 DATE
   ____________________________
     NAME (PRINT)                                                        TITLE


           MVAC RECOVER, RECOVER/RECYCLE OR RECOVER/RECYCLE/RECHARGE
                   EQUIPMENT CERTIFICATION FORM INSTRUCTIONS

Motor vehicle refrigerant recover, recover/recycle, or recover/recycle/recharge equipment must be
acquired by January 1, 1992 and certified to EPA on or before January 1, 1993 under Section 609 of the
Clean Air Act. To certify your equipment, please complete the above form according to the following
instructions and mail to the appropriate EPA region based on where your establishment is located.

1 Please provide the name, address, and telephone number of the establishment where the
    equipment is located.

2 Please provide the name brand, model number, year and serial number(s) of the equipment
    acquired for use at the above establishment.

3 The certification statement must be signed by the person who has acquired the equipment (the
  person may be the owner of the establishment or another responsible officer). The person who signs    is certifying that they have acquired the equipment, that each individual authorized to use the equipment is properly trained and certified, 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 section 609 Enforcement Contact; EPA Region I; Mail Code OES04-2; 5 Post Office Square; Boston, MA 02109
      
New York, New Jersey, Puerto Rico, Virgin Islands
      CAA section 609 Enforcement Contact; EPA Region II; Mail Code 2DECA-AC; 290Broadway, 21st Floor; New York, NY 10007-1866

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia
      CAA section 609 Enforcement Contact; EPA Region III--Wheeling Office; Mail Code 3AP20; 1060 Chapline Street, Suite 303; Wheeling, WV 26003-2995

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina,
      Tennessee
      CAA section 609 Enforcement Contact; EPA Region IV; Mail Code APT-AE; Atlanta Federal Center; 61 Forsyth Street, SW.; Atlanta, GA 30303-8960

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin
      CAA section 609 Enforcement Contact, EPA Region V; Mail Code AE17J; 77 West Jackson Blvd.; Chicago, IL 60604-3507

Arkansas, Louisiana, New Mexico, Oklahoma, Texas
      CAA section 609 Enforcement Contact; EPA Region VI; Mail Code 6EN-HM; 1445 Ross Avenue, Suite 1200; Dallas, Texas 75202

Iowa, Kansas, Missouri, Nebraska
      CAA section 609 Enforcement Contact; EPA Region VII; Mail Code AWMD/APCO; 901 North 5th Street; Kansas City, KS; 66101

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming
      CAA section 609 Enforcement Contact, EPA Region VIII, Mail Code 8ENE-AT,
      1595 Wynkoop St., Denver, CO 80202

American Samoa, Arizona, California, Guam, Hawaii, Nevada
      CAA section 609 Enforcement Contact; EPA Region IX; Mail Code AIR-5; 75
      Hawthorne Street; San Francisco, CA 94105

Alaska, Idaho, Oregon,Washington
      CAA section 609 Enforcement Contact; EPA Region X; Mail Code OAQ-107; 1200 Sixth Avenue; Seattle, WA 98101
