5900-74 Qualified Product Information Form for Geothermal Heat P

OMB Control No. 2060-0528 Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Geothermal Heat Pumps

Office of Atmospheric Programs

Energy Star^® product information form for use by Energy Star qualified geothermal heat pump partners

(Companies who have joined Energy Star for geothermal heat pumps 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 geothermal heat pump products. If you need additional space, please copy this form.

Company Name: ________________________________ Product Contact Information:_________________ (As listed in Partnership Agreement) (For public requesting product information)

Name: _________________________________________________

Tested by: ______________________________________ Tel: _____________________

(Name of Firm or Self-Tested)

Fax:_________________________

Email: _________________________________________________

Additions to Qualifying Products List:

Manufacturer Name (Trade Name)	Product Family Name	Product Type1	COP Rating	EER Rating	Model Series2

Is product shipped with Energy Star label:

________ in product literature? ________ on Internet site? ________ on product packaging?

If answer to any of the above is No, explain why: ________________________________________________________________________________________________

Please sign below:

Signature: ________________________________________ Date: __________

Printed Name: _____________________________________

Thank you for your assistance. The Qualifying Products List is available through the Energy Star Hotline

(1-888-STAR-YES/1-888-782-7937) and Web site (http://www.energystar.gov).

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.

1 Please specify product type according to the product types listed in Section IV.B.1. Table 1 and Table 2 of the Eligibility Criteria

(i.e., Closed/Open Loop, Closed/Open Loop w/integrated WH, DX, DX w/integrated WH).

2 Please simplify model series information when possible (e.g., “All models beginning with...”).

Please submit your completed QPI Form to ENERGY STAR for Geothermal Heat Pumps

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 US mark.

EPA Form No. 5900-74