                                       
                        ENVIRONMENTAL PROTECTION AGENCY
                       PART 1: ESTABLISHMENT INFORMATION
Name of Establishment
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Street
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(Area Code) Telephone Number

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City                                 State                     Zip Code

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PART 1: ESTABLISHMENT INFORMATION
Name of Establishment
--------------------------------------------------------------------------------


Street
--------------------------------------------------------------------------------


(Area Code) Telephone Number

--------------------------------------------------------------------------------


City                                 State                     Zip Code

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EPA requires manufacturers of small cans of automotive refrigerant to keep records of test data and log forms that demonstrate compliance with the allowable leakage rate (40 CFR §82.154(c)(2)). 
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. The number and expiration date are displayed in the upper right corner of the form. The public reporting and recordkeeping burden for this collection of information is estimated to average 2 hours per year. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Avenue NW, Washington, D.C. 20460.  Include the OMB control number in any correspondence.  Do not send the completed form to this address.

EPA requires manufacturers of small cans of automotive refrigerant to keep records of test data and log forms that demonstrate compliance with the allowable leakage rate (40 CFR §82.154(c)(2)). 
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. The number and expiration date are displayed in the upper right corner of the form. The public reporting and recordkeeping burden for this collection of information is estimated to average 2 hours per year. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Avenue NW, Washington, D.C. 20460.  Include the OMB control number in any correspondence.  Do not send the completed form to this address.

PART 2: SMALL CAN TEST DATA FORM
Enforcement Lot ID:
                                                                               
                                                                          Full:

                                                                       Upright:

                                                                       T= 73 F:


                                                                               
                                                                     Half full:

                                                                      Inverted:

                                                                      T= 130 F:


                                                                          Date:

                                                                          Date:





                                    Can ID
                              Initial time (hour)
                              Initial weight (g)
                               Final time (hour)
                               Final weight (g)
                                     Delta
                                     days
                               Delta weight (g)
                          Adjusted annual rate (g/yr)









































































                                                             Number of Samples:

                                                             Average Loss Rate:

                                                                    Technician:

                                                            Standard Deviation:

Comments:




PART 2: SMALL CAN TEST DATA FORM
Enforcement Lot ID:
                                                                               
                                                                          Full:

                                                                       Upright:

                                                                       T= 73 F:


                                                                               
                                                                     Half full:

                                                                      Inverted:

                                                                      T= 130 F:


                                                                          Date:

                                                                          Date:





                                    Can ID
                              Initial time (hour)
                              Initial weight (g)
                               Final time (hour)
                               Final weight (g)
                                     Delta
                                     days
                               Delta weight (g)
                          Adjusted annual rate (g/yr)









































































                                                             Number of Samples:

                                                             Average Loss Rate:

                                                                    Technician:

                                                            Standard Deviation:

Comments:




SMALL CAN TEST DATA FORM 
  PART 3: BALANCE DATA LOG FORM
  
                                     Rec #
                                     Date
                                     Time
                                     Proj.
                                     Prot.
                                     Tech.
                                      QC
                                     Code
                                      Can
                                   Recorded
                                     Grams
                                    Comment
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                     Type
                                      ID#
                                       
                                       
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