5900-64 Qualified Product Information Form for Bottled Water Coo

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Bottled Water Coolers

Office of Atmospheric Programs

ENERGY STAR Product Information Form for Use by ENERGY STAR Bottled Water Cooler Partners

(Companies who have joined ENERGY STAR for Bottled Water Coolers by signing a Partnership Agreement)

You may use this form to report only those products that are sold under your company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join the program and report its own products. Information from this form will be added to the list of ENERGY STAR qualified water cooler products.

Product Contact Information:

(For verification of product information)

Name:

Tel:

Fax:

Email:

C
ompany Name:

(As listed in Partnership Agreement)

Product Category (please check one)
___ Cold Only Bottled Unit ___ Hot and Cold Bottled Unit ___ Cook and Cold Bottled Unit
Brand Name	Model Series Name	Model Number		Standby Energy Consumption (kW-hours/day)	Date Product Available

Tested By: _____________________________________ Date Tested: ____________________________

(Name of Independent Testing Firm or Self-Tested)

By checking the boxes below, you are confirming that you have reviewed and will meet the labeling requirements outlined in the ENERGY STAR Program Requirements for Bottled Water Coolers. These requirements include the following:

On top/front of product

In product literature

On Internet site

On product packaging (recommended)

I
f answer to any of the above is No, explain why:

Does this model have a refrigerated compartment? Yes_________ No__________

Please check one or more of the following international markets where these products are sold (if applicable):

Australia/New Zealand	EU	Mexico
Canada	Japan	Taiwan

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

Please submit your completed QPI Form to ENERGY STAR for Water Coolers

Email: [email protected], Fax: (202) 862-1144

1725 Eye St, NW, Suite 1000, Washington, DC 20006

Energy Star, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA

Toll-free number 1-888-STAR-YES, Web site http://www.energystar.gov

Energy Star is a registered mark.

EPA Form No. 5900-64