Form Appendix A to Subp Appendix A to Subp Compliance Statement and Certification Report

Appendix A to Subpart F of Part 430—Compliance Statement and Certification Report
COMPLIANCE STATEMENT
Product:____________________
Manufacturer's or Private Labeler's Name and Address:
____________________
____________________
____________________
This compliance statement and all certification reports submitted are in accordance with 10 CFR Part 430
(Energy or Water Conservation Program for Consumer Products) and the Energy Policy and Conservation
Act, as amended. The compliance statement is signed by a responsible official of the above named
company. The basic model(s) listed in certification reports comply with the applicable energy conservation
standard or water (in the case of faucets, showerheads, water closets, and urinals) conservation standard.
All testing on which the certification reports are based was conducted in conformance with applicable test
requirements prescribed in 10 CFR part 430 subpart B. All information reported in the certification report(s)
is true, accurate, and complete. The company is aware of the penalties associated with violations of the Act,
the regulations thereunder, and is also aware of the provisions contained in 18 U.S.C. 1001, which prohibits
knowingly making false statements to the Federal Government.
Name of Company Official:____________________
Signature:____________________
Title:____________________
Firm or Organization:____________________
Address:____________________
Telephone Number:____________________
Facsimile Number:____________________
Date:____________________
Third Party Representation (if applicable)
For certification reports prepared and submitted by a third party organization under the provisions of §430.62
of 10 CFR part 430, the company official who authorized said third party representation is:
Name:____________________
Title:____________________
Address:____________________
Telephone Number:____________________
Facsimile Number:____________________
The third party organization submitting the certification report on behalf of the company is:
Third Party Organization:____________________
Address:____________________
Telephone Number:____________________
Facsimile Number:____________________
CERTIFICATION REPORT
Date:____________________
Product Type:____________________
Product Class:____________________
Manufacturer:____________________
Private Labeler (if applicable):____________________

Name:____________________
Title:____________________
Address:____________________
Telephone Number:____________________
Facsimile Number:____________________
1
For Existing, New, or Modified Models :

1

Provide specific product information including, for each basic model, the manufacturer's model
numbers and the information required in §430.62(a)(4)(i) through (a)(4)(xvii)).
For Discontinued Models2 :
2

Provide manufacturer's model number.

[63 FR 13321, Mar. 18, 1998]