TIF 25150B Refrigerant Recovery Machine - Manual (Page 21)

THE UNITED STATES ENVIRONMENTAL PROTECTION
AGENCY (EPA) REFRIGERANT RECOVERY AND RECYCLING DEVICE
ACQUISITION CERTIFICATION FORM
EPA regulations have required establishments that service or dispose of refrigerant or air conditioning
equipment to certify that they have acquired recovery and recycling devices that meet the EPA standards
for such devices since August 12. 1993. 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 ADDRESS CAN BE FOUND ON THE NEXT PAGE OF THIS MANUAL.
Part 1: ESTABLISHMENT INFORMATION UNIT STORAGE ADDRESS
Name of Establishment
Street
City
Zip Code
State County
(Area Code) Telephone Number
Name of Establishment
Street
City
Zip Code
State County
(Area Code) Telephone Number
NUMBER OF SERVICE VEHICLES BASED AT ESTABLISHMENT
Part 2: REGULATORY CLASSIFICATION
Identify the type of work performed at your establishment. Check all boxes 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
Name of Device Manufacturer Model # Month/Year Mfg# (if any) Self Contained
Part 4: SIGNATURE
I certify that the establishment named in part 1. has acquired the refrigerant recovery or recycling
devices listed in part 3. and that this equipment will be properly used in service (and/or) disposing
of appliances. I also certify that the information supplied herein is correct and true.
Signature of owner / Responsible Officer Date Name (please print) Title
Public reporting burden for this collection of information is estimated to vary from 20-60 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 the burden estimate or any other aspect of this collec-
tion of information, including suggestions for reducing the burden to: Chief information Policy Branch EPA, 401 M St. S.W. (PM223Y),
Washington, DC 20460 and to the Office of information and Regulatory Affairs, Office of Management and Budget, Washington, DC
20503 marked Attention, Desk Officer for EPA.
DO NOT SEND THIS FORM TO THE ABOVE ADDRESSES. ONLY SEND COMMENTS TO THESE ADDRESSES
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