OMB No. 2060-0247

Expires: [ADD DATE ONCE APPROVED]

MVAC RECOVER, RECOVER/RECYCLE OR RECOVER/RECYCLE/RECHARGE

EQUIPMENT CERTIFICATION 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.

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.
OMB No. 2060-0247

Expires: [ADD DATE ONCE APPROVED]

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