Form Approved OM B No. 2060 - 0256 Expires: 07/31/2010

EPA FORM 7610 - 31 

### ENVIRONMENTA L PROTECTION AGENCY

REFRIGERA NT RECOVERY OR RECYCLING DEVICE AC QUISITION CERTIFICATION FORM EPA regulations require establishments that service or dispose of refrigeration or air- conditioning equipment to certify that they have acquired recover y or rec yc ling devices that meet EPA standards for such devices. To certify that you have acquired equi pm ent, please complete this form according to the instructions and mail it to the appropriate EPA Regional Office. BOTH THE INSTRUCTIONS A ND M AI LING A DDRESSES CA N BE FOUND ON THE REVERSE SIDE OF THIS FORM. PA RT 1: EST ABLISHM ENT INFORM AT ION

Name of Establishment Street

(Area Code) Telephone Number City State Zip Code

Number of Service Vehicles Based at Establishment County

PA RT 2: REGUL AT ORY CLASSIFICA TION 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 PA RT 3: DEVICE IDENTIFICA TION Name of Device(s) Manufacturer Model Number Year Serial Number (if any) Check Box if Self- Contained 

### 1.  2.  3. 

###  4. 

###  5.  PA RT 4: CERTIFICA

TION SIGNA

TURE I certify that the establishment in Part 1 has acquired the refrigerant recovery or recycling device(s) listed in Part 2, tha t the establishment is complying with Section 608 regulations, and that the information gives is true and correct.Form Approved OM B No. 2060 - 0256 Expires: 07/31/2010

EPA FORM 7610 - 31 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 t his 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 em ployees of the establishment. The term “small appliance” refers to an y 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 p ackaged 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 o f 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 contai ned in the appliance. On the other hand, s ys tem - 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 T ype B and/or T yp e 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 identifi ed by writing “homemade” in the column provided for listing the name of the device manufacturer. T yp e A or T ype B establishments can use homemade devices manufactured before November 15, 1993. T ype C or T yp e D establishments can use homemade manufactured anytime. If, however, a T yp e C or T ype D establishment is using hom em ade equipment manufactured after November 15, 1993, then it must not use these devices for service jobs.Form Approved OM B No. 2060 - 0256 Expires: 07/31/2010

EPA FORM 7610 - 31



###  ii

 EPA REGIONA L 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 Conta ct: 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; Da llas, 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, Mar yl and, Pennsylvania, Virginia, W est Virginia CAA 608 Enforcement Contact: EPA Region III -Wh eeling Office; Mail Code 3AP12; 303 Methodist Building; 11 th and Chapline Streets; W heeling, WV26003 Colorado, Montana, North Dakota, South Dakota, Utah, Wyom ing CAA 608 Enforcement Contact: EPA Region VIII; Mail Code 8ENF - T; 999 18 th Street, Suite 500; Denver, CO 80202 Alabama, Florida, Georgia, Kentuck y, 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 Am erican 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, Wi sconsin CAA 608 Enforcement Contact: EPA Re gion V; Mail Code AE - 17J; 77 We st Jackson Blvd.; Chicago, IL 60604 Alaska, Idaho, Oregon, Wa shington CAA 608 Enforcement Contact: EPA Region X; Mail Code OAQ - 107; 1200 Sixth Ave.; Seattle, W A 98101Form Approved OM B No. 2060 - 0256 Expires: 07/31/2010

EPA FORM 7610 - 31



###  iii

 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, ma intenance, 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, maint enance, 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 regulation s (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 tim e 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; adju st 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 av ailable for public viewing at the Air and Radiation Docket and Information Center in the EPA Docket Center (EPA/DC), EPA W est, Room B102, 1301 Constitution Ave., N W, W ashington, 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 syste m, 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 , Wa shington, 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.