OM B No. 2060

- 0247 Ex pires: [ADD DATE ONCE APPROVED ] **MVA C RECOVER, RECOVER/RECYCLE OR RECOVER/RECYCLE/RECHA**  **RGE**

**EQUIPMENT CERTIFICA TION 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/recy cle/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 OW NER/ OPERATOR DATE



### ____________________________ NAME (PRINT) TITLE
MVAC RECOVER, RECOVER/RECYCLE OR RECOVER/RECYCLE/RECHARGE

EQUIPMENT CERTIFICATION FORM INSTRUCTIONS
Motor vehicle refrigerant recover, recover/rec yc le, or recover/rec yc le/recharge equipment must be acquired by Januar y 1, 1992 and certified to EPA on or before January 1, 1993 under Section 609 of the Clean Air Act. To certify y our 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 W HICH THE ESTABLISHMENT IS LOCATED. MAILING ADDRESSES CAN BE FOUND ON THE REVERSE SIDE OF THIS FORM.OM B No. 2060

- 0247 Ex pires: [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 Cont act; 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 Enfo rcement Contact; EPA Region II; Mail Code 2DECA

- AC ; 290Broadway, 21st Floor; New York, NY 10007

- 1866 Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, W est Virginia CAA section 609 Enforcement Contact; EPA Region III

-- Wh eeling Office; Mail Code 3AP20; 1060 Chapline Street, Suite 303; W heeling, W V 26003

- 2995 Alabama, Florida, Georgia, Kent ucky, Mississippi, North Carolina, South Carolina, Tennessee CAA section 609 Enf orcement Contact; EPA Region IV; Mail Code APT

- AE ; Atlanta Federal Center; 61 Forsyth Street, SW .; Atlanta, GA 30303

- 8960 Illinois, Indiana, Michigan, Minnesota, Ohio, Wi scons in CAA section 609 Enf orcement Contact, EPA Region V; Mail Code AE17J ; 77 We st Jackson Blvd.; Chicago, IL 60604

- 3507 Arkansas, Louisiana, New Mexico, Oklahoma, Texas CAA section 609 Enfo rcement Contact; EPA Region VI; Mail Code 6EN

- HM ; 1445 Ross Avenue, S uite 1200; Dallas, Texas 75202 Iowa, Kansas, Missouri, Nebraska CAA section 609 Enforcement Contact; EPA Region VII; Mail Code A WM D /APCO ; 901 North 5th Street; Kansas City, KS; 66101 Colorado, Montana, North Dakota, South Dakota, Utah, Wy oming CAA sectio n 609 Enforcement Contact, EPA Region VIII, Mail Code 8ENE

- A T, 1595 W yn koop 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,W ashington CAA section 609 Enforcement Contac t; EPA Region X; Mail Code OAQ

- 107 ; 1200 Sixth Avenue; Seattle, WA 98101