5900-170 Qualified Product Information Form for Commercial Ice Ma

OMB No. 2060-0528
Approval Expires 03/31/2011
United States

ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460
Qualified Product Information Form for Commercial Ice Machines
Office of Atmospheric Programs
ENERGY STAR® Qualified Product Information (QPI) Form for use by ENERGY STAR Commercial Ice Machine Partners (Companies
who have joined ENERGY STAR for Ice Machines by signing the Partnership Agreement). Information from this form will be added to
the list of ENERGY STAR Qualified Commercial Ice Machines on the ENERGY STAR Web site at www.energystar.gov.
Note: Partners may use this QPI form to report only those products that are sold under the company’s brand name. If your company
sells its equipment to another company that uses its own brand name, that company must join ENERGY STAR and report its own
models. Please copy this form and return one for each qualifying model to the address or fax number provided in Section VI, below.

I

Contact Information

Company Name: (as listed in the PA)

Name of Person Submitting Information:
Tel:

Fax:

E-mail:

II Qualifying Model Information
Brand

Equipment Type*

Model Name

Type of Ice**

Ice Making
Technology^

Model Number

Date Available on Market

* Indicate IMH (ice making head), RCU (remote condensing unit, please indicate with/without condensing unit), or SCU (self contained

unit).

**Indicate cubed, flake, or nugget. Note: Only cubed machines can qualify for ENERGY STAR.

^ Indicate air-cooled or water-cooled. Note: Only air-cooled machines can qualify for ENERGY STAR.

ENERGY STAR, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA
Toll-free number: 1-888-STAR-YES Web site: www.energystar.gov
EPA Form No. 5900-170
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OMB No. 2060-0528
Approval Expires 03/31/2011

III Energy and Water Efficiency Performance^^
Harvest Rate
(lbs ice/day)

Energy Use
(kWh/100 lbs ice)

Potable Water Use
(gal/100 lbs ice)

^^As determined by Air-Conditioning and Refrigeration Institute (ARI) Standard 810-2006, Performance Rating of Automatic
Commercial Ice-Makers. Note: Energy use must be rounded and reported to three significant figures for ENERGY STAR
qualification. This data will then be rounded to the first decimal place for posting to the Web site, consistent with the ARI
Directory.

IV Testing Requirements
Tested by: (Name of Independent Testing Firm or Self Tested)
Date Tested:

V Labeling Requirements
By checking the items below, you are confirming that you have reviewed and will meet the labeling requirements outlined

in the ENERGY STAR Program Requirements for Commercial Ice Machines. These requirements include:

____ On Top/Front of Product

____ In Product Literature

____ On Internet Site

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

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

___ Canada

___ EU

___ Japan

___ Mexico

___ Taiwan

VI Contact Information
Please submit your completed QPI Forms in one of the following ways:
E-mail: [email protected]
Fax: (202) 862-1144 c/o Rebecca Duff, ICF International
US Mail/Overnight Express: Rebecca Duff, ICF International, 1725 Eye Street NW, Suite 1000, Washington, DC 20006

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.

ENERGY STAR, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA
Toll-free number: 1-888-STAR-YES Web site: www.energystar.gov
EPA Form No. 5900-170
2