5900-60 Qualified Product Information Form for Boilers

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Boilers

Office of Atmospheric Programs

Energy Star^® product information form for use by Energy Star qualified boiler partners

(Companies who have joined Energy Star for boilers 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 boiler products. If you need additional space, please copy this form.

Company Name: ________________________________ Product Contact Information (for public requesting product information)

(As listed in Partnership Agreement)

Name: _________________________________________________

Tested by: ______________________________________

(Name of Firm or Self-Tested) Tel: _____________________ Fax:_________________________

Email: _________________________________________________

Additions to Qualifying Products List:

Manufacturer Name (Trade Name)	Product Family Name	Type (i.e., Steam or Water)	Fuel Type (e.g. Gas, Oil, etc.)	Provides Hot Water Heating?	AFUE Rating	CAafue Rating1	Model Series2

Is product shipped with Energy Star label:

________ in product literature? (required) ________ on Internet site? (required) ________ on product packaging? (recommended)

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.

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 Combination Space-Heating and Water Heating appliances provide both space conditioning (boiler) and hot water heating with one appliance or energy source. The combination appliance circulates hot water from the water heater through a heat exchanger in the air handler. A blower will move the heated air through a standard duct system. In the summer, an air conditioner is connected to the exchanger and the system functions similarly, with cool air being pushed through the ductwork. When the primary heating source of the combined appliance is a residential boiler, the Combined Appliance Annual Fuel Utilization Efficiency (“CAafue”) is the same as the AFUE of the boiler as determined by DOE test procedures specified in 10 CFR 430.

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

Please submit your completed QPI Form to ENERGY STAR for Boilers

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. 5900-60