5900-32 RAD Voluntary Reporting Form

Responsible Appliance Disposal Program

RADVOLUNTARYREPORTINGFORM_v2.xlsm

Responsible Appliance Disposal Program

OMB: 2060-0703

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2060-0703 can be found here:

Document [xlsx]

Download: xlsx | pdf

Overview

Instructions & Definitions
Step 1-Contact and Program Info
Step 2-Third Party Information
Step 3-Refrigerators
Step 3-Stand-Alone Freezers
Step 3-Air-Conditioning Units
Step 3-Dehumidifiers
Step 4-Units Jointly Processed
Step 5-QA_Input Data Summary
Step 5-Env Benefits
Step 5-Energy Impacts
Step 6-Partner Feedback
Step 7-Confirmation

Sheet 1: Instructions & Definitions




		ENVIRONMENTAL PROTECTION AGENCY
		Washington, DC 20460
		Responsible Appliance Disposal (RAD) Program Annual Reporting Form
		Office of Air & Radiation

		INTRODUCTION

		The U.S. EPA’s Responsible Appliance Disposal (RAD) Program for utilities, manufacturers, retailers, states, and other qualifying organizations is a voluntary program that helps protect the ozone layer and reduce emissions of greenhouse gases. Through the Program, partners dispose of old refrigerators, freezers, dehumidifiers, and window air-conditioning units using the best environmental practices available and going beyond what is required by federal law.

		This reporting form will allow EPA to track and quantify the environmental benefits achieved by your program, and ultimately, those achieved by the RAD Program as a whole.

		CONFIDENTIALITY

		All information provided in this report will be considered strictly confidential. No company-specific information will be disclosed to the public; all company data will be aggregated into summary reports before being made available to the public.

		INSTRUCTIONS

		Please complete all worksheets that are applicable to your program. Within each worksheet, please provide information for all fields requested. The purpose of each worksheet and the type of information requested in each is outlined below. Please ensure that all of the following steps have been completed before submitting the reporting form.
			Step 1: Contact and Program Information Provide your contact and program information.
			Step 2: Third-Party Information Enter contact information for and details about all companies providing appliance collection and processing services under your program.
			Step 3: Activity Data on Processed Units Complete a Step 3 worksheet for each appliance type included in your program. There are separate worksheets for Refrigerators, Stand-Alone Freezers, Air Conditioning Units, and Dehumidifiers. For each type of appliance processed by your program, complete the worksheet to provide the number of units processed and the amounts of materials/components recovered from those units.
			Step 4: Units Handled Jointly by Your Organization and Another RAD Partner Complete this worksheet if any appliances were jointly processed by your organization and another RAD partner. When reporting the units by refrigerant type and blowing agent type, report only the units processed with refrigerant recovery and foam recovery, respectively.
			Step 5: Summary of Input Data for Quality Assurance and Program Benefits a) Review Step 5 Summary of Input Data for Quality Assurance worksheet to ensure that the information entered in Step 3 worksheets is accurate. This worksheet is used for quality assurance purposes and does not require any data input. b) Review Step 5 Summary of Program's Environmental Benefits and Step 5 Summary of Program's Gross Energy Impacts from Removal of Old Units worksheets to learn about the environmental and/or energy impacts associated with your program.
			Step 6: Partner Feedback Provide qualitative information on your program and any input on the RAD program.
			Step 7: Confirmation Check and sign a statement confirming that all information provided in this form is accurate, to the best of your knowledge.


		DEFINITIONS

			Recover: To remove a material (in any condition) from an appliance and then store it externally without necessarily testing or processing it in any way.

			Reclaim: To reprocess ODS and ODS substitutes using specialized machinery to at least the requirements specified in the ARI Standard 700, Specifications for Fluorocarbon Refrigerants, and to verify using the analytical methodology prescribed in the Standard.

			Stockpiling with Intent to Reclaim: To store refrigerant or foam-blowing agent on-site at the recycling facility where the unit was processed with the intent of later reclaiming the substance(s).

			Recycle: To extract material from an appliance and process it for reuse. Recycling durable components, such as metals, rubber, plastic, and glass, entails reprocessing them for future use in other manufactured products, and not reuse of the appliance itself. When recycling used oil, refrigerants must be recovered from the used oil to the fullest extent possible, and the used oil cannot be mixed with used oil from sources other than refrigeration units.

			Destroy: To cause the expiration of a controlled substance. Destruction does not result in a commercially useful end product. For refrigerant or foam-blowing agent, destruction must be performed in accordance with the guidelines in 40 CFR §82.3. For PCBs, which are found in capacitors manufactured before 1980, destruction must be in accordance with 40 CFR §761.

			Stockpiling with Intent to Destroy: To store refrigerant or foam-blowing agent on-site at the recycling facility where the unit was processed with the intent of later destroying the substance(s).

			Dispose: Mercury waste, such as switches and relays, must be recovered from appliances prior to disposal or shredding, sent to a qualified recovery facility that has appropriate hazardous waste management permits, and managed in accordance with applicable federal, state, and local hazardous waste regulations (e.g., waste must be properly packaged prior to transport). The federal hazardous waste regulations under the Resource Conservation and Recovery Act (RCRA) can be found in 40 CFR §260 - 279. Used oil must be disposed in accordance with 40 CFR §279.81.

			Energy Cost for Residential Consumers ($/kWh): the energy cost paid by consumers, which may include a customer charge, distribution charge, transmission charge, transition charge, generation service charge, or other charges based on the electricity pricing scheme in your region.



		SEND COMPLETED FORMS VIA EMAIL TO:


		BURDEN STATEMENT

		The public reporting and recordkeeping burden for this collection of information is estimated to average 6 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.
		Revised 1/2016

Sheet 2: Step 1-Contact and Program Info

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

Step 1: Contact and Program Information

Instructions: Provide your contact and program information (Tables A and B) on this page.

A. Contact Information

Name of RAD Partner:

Reporting Period:

MM/DD/YYYY

Primary Contact:

Alternate Contact:

Contact Name

Address

Daytime Phone

Fax

E-mail Address

B. Program Information

Please select the RAD partner category your program falls under:

Indicate which appliance types are included in your program:

Refrigerators

Stand-Alone Freezers

Air-Conditioning Units

Dehumidifiers

Does your program jointly process/administer some appliances with another RAD partner?

Does your program provide an incentive (e.g., financial) to encourage disposal of old,
working refrigerated appliances?

Revised 1/2016

Sheet 3: Step 2-Third Party Information

Step 2: Third-Party Information

Instructions: In Tables A-E below, please indicate the contact information for all companies used by your program to collect/treat appliances and recovered materials in order to fulfill the requirements of the RAD Program. Indicate an "x" for the role fulfilled by each company. Note that you may need to contact third-party providers in order to obtain the names and addresses of the companies that provide the services specified. Please add additional rows if needed.

A. Haul-Away and Demanufacturing Companies

Company Name

Contact Name

Phone Number

Address

Company Role

Appliance Haul-Away

Refrigerant Recovery

Foam/Blowing Agent Recovery

Mercury Recovery

Used Oil Recovery

PCBs Recovery

Example Company A

John Smith

123-456-7890

123 Street Name
City, State, Zipcode

B. Refrigerant Reclamation and Destruction Facilities

Company Name

Contact Name

Phone Number

Address

Facility Role

Type of Destruction Technology (if applicable)

Reclamation

Destruction

C. Foam/Blowing Agent Recovery Process

Please use an "x" in the appropriate column to indicate the appliance items from which foam is recovered and the foam recovery process used.

Company Name

Foam Recovery Items

Foam/Blowing Agent Recovery Process

Doors

Case

Manual
(saw and scrape/filet)a

Semi-Automated
(saw, scrape/filet, and process to recover blowing agent)b

Fully Automated (appliance processed whole to recover blowing agent)c

Other: please describe

Name of Automated Technology/Equipment Type
(if an automated technology is selected)d

Example Company B

SEG

a Manual: The appliance is deconstructed with the use of hand or electric saws; foam is removed manually by scraping or fileting. The foam is then destroyed with the blowing agent intact.

b Semi-Automated: The appliance is deconstructed with the use of hand or electric saws; the intact foam panels are then processed using an automated technology to recover the blowing agent.

c Fully Automated: The whole appliance is processed using an automated technology to recover the blowing agent.

d For example, Adelmann, SEG, and URT.

D. Foam/Blowing Agent Reclamation and Destruction Facilities

Facility Name

Contact Name

Phone Number

Address

Facility Role

Type of Destruction Technology (if applicable)

Reclamation

Destruction

E. Hazardous Materials Recycling and Disposal Facilities

Facility Name

Contact Name

Phone Number

Address

Facility Role

Recycling/ Disposal of Used Oil

Disposal of PCBs

Disposal of Mercury

Revised 1/2016

Sheet 4: Step 3-Refrigerators



Step 3: Activity Data on Refrigerators					MM/DD/YYYY	to	MM/DD/YYYY
Instructions: All partners should complete Tables A and B. If your program provides an incentive (e.g., financial) to encourage the disposal of old, working refrigerated appliances, please also complete Table C. When populating cells, please use the units provided; do not add text to specify units. This form only recognizes numbers.
A. Units Processed
Please complete the gray cells below. Enter the total number of units processed by your program by refrigerant type and insulating material type in column D. Specify the number of units processed with refrigerant recovery and foam recovery in cells E11 to E13 and cells E16 to E22, respectively, and whether foam was recovered from appliance doors (cells F16 to F19). Also, provide the average age of appliances collected (cell D9), and whether the information on refrigerant and blowing agent types is based on assumptions or data (cells F11 to F13 and cells G16 to G22, respectively). If any of the units reported in column D were jointly processed/administered with another RAD Utility, Retailer, Manufacturer, or State Partner, please indicate the number of these units in Step 4 - Units Jointly Processed; the units reported in this table should be inclusive of the units reported in Step 4. If you wish to provide additional information (e.g., regarding types of refrigerants or insulating materials not listed below) or highlight uncertainties in your reporting, please do so in the “Comments” box.

Total Number of Units Processed
Average Age of Appliances Collected (yrs)
Refrigerant Type	Total Number of Units Processed	Number of Units Processed with Refrigerant Recovery	Refrigerant Type Based On:	Comments:
CFC-12
HFC-134a
Other
Total	0	0
Insulating Material Type	Total Number of Units Processed	Number of Units Processed with Foam Recovery	Was Foam Recovered From Appliance Doors?	Insulating Material Type Based On:	Comments:
CFC-11 Blowing Agent
HCFC-141b Blowing Agent
HFC-134a Blowing Agent
HFC-245fa Blowing Agent
Cyclopentane Blowing Agent
Fiberglass
Other
Total	0	0

B. Fate and Quantity of Substances Recovered

Please complete the table below to provide the total amount of appliance components recovered by your program during the current reporting period. If any substances recovered during the current reporting period are currently in storage, please report on the intended fate of the substance (e.g., stockpiling with intent to reclaim/destroy). Refer back to the Instructions for Use for definitions of the fates for each component. For any fields that do not apply to your program, please enter "0" under "Total Amount" in column F. For every non-zero value entered in column F, indicate whether the quantity specified is based on actual measurements or on assumptions by selecting the appropriate option in column H. If you wish to clarify uncertainties about the data provided, or wish to provide further information, please use the space for “Additional Comments” at the bottom of this worksheet.
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Refrigerant (including that recovered from compressor oil)	CFC-12
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-134a
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
Foam-Blowing Agent*	CFC-11
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HCFC-141b
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-134a
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-245fa
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
Used Oil	Recycled			(gal)
Used Oil	Disposed			(gal)
Metal	Ferrous Metal Recycled			(lb)
Metal	Non-Ferrous Metal Recycled			(lb)
Plastic	Recycled			(lb)
Glass	Recycled			(lb)
PCB-Containing Capacitors	Destroyed			(# of capacitors)
*Foam-blowing agent typically represents only 10% of the total foam weight.
C. Energy Savings
Please complete the table below if your program provides an incentive (e.g., financial) to encourage the disposal (i.e., without replacement) of old, working refrigerated appliances.

Average Number of Remaining Years of Useful Life		Source: Department of Energy (DOE). 2009.Technical Support Document for the Final Rule on Residential Refrigerators, Refrigerator-Freezers and Freezers. Available online at www1.eere.energy.gov/buildings/appliance_standards/pdfs/refrig_finalrule_tsd.pdf
Average Energy Consumed/Year/Unit (kWh)
Average Energy Cost for Residential Consumers ($/kWh) [please provide the average cost during the current program period]

Additional Comments:







Revised 1/2016

Sheet 5: Step 3-Stand-Alone Freezers



Step 3: Activity Data on Stand-Alone Freezers					MM/DD/YYYY	to	MM/DD/YYYY
Instructions: All partners should complete Tables A and B. If your program provides an incentive (e.g., financial) to encourage the disposal of old, working refrigerated appliances, please also complete Table C. When populating cells, please use the units provided; do not add text to specify units. This form only recognizes numbers.
A. Units Processed
Please complete the gray cells below. Enter the total number of units processed by your program by refrigerant type and insulating material type in column D. Specify the number of units processed with refrigerant recovery and foam recovery in cells E11 to E14 and cells E17 to E23, respectively, and whether foam was recovered from appliance doors (cells F17 to F20). Also, provide the average age of appliances collected (cell D9), and whether the information on refrigerant and blowing agent types is based on assumptions or data (cells F11 to F14 and cells G17 to G23, respectively). If any of the units reported in column D were jointly processed/administered with another RAD Utility, Retailer, Manufacturer, or State Partner, please indicate the number of these units in Step 4 - Units Jointly Processed; the units reported in this table should be inclusive of the units reported in Step 4. If you wish to provide additional information (e.g., regarding types of refrigerants or insulating materials not listed below) or highlight uncertainties in your reporting, please do so in the “Comments” box.

Total Number of Units Processed
Average Age of Appliances Collected (yrs)
Refrigerant Type	Total Number of Units Processed	Number of Units Processed with Refrigerant Recovery	Refrigerant Type Based On:	Comments:
CFC-12
HCFC-22
HFC-134a
Other
Total	0	0
Insulating Material Type	Total Number of Units Processed	Number of Units Processed with Foam Recovery	Was Foam Recovered From Appliance Doors?	Insulating Material Type Based On:	Comments:
CFC-11 Blowing Agent
HCFC-141b Blowing Agent
HFC-134a Blowing Agent
HFC-245fa Blowing Agent
Cyclopentane Blowing Agent
Fiberglass
Other
Total	0	0

B. Fate and Quantity of Substances Recovered

Please complete the table below to provide the total amount of appliance components recovered by your program during the current reporting period. If any substances recovered during the current reporting period are currently in storage, please report on the intended fate of the substance (e.g., stockpiling with intent to reclaim/destroy). Refer back to the Instructions for Use for definitions of the fates for each component. For any fields that do not apply to your program, please enter "0" under "Total Amount" in column F. For every non-zero value entered in column F, indicate whether the quantity specified is based on actual measurements or on assumptions by selecting the appropriate option in column H. If you wish to clarify uncertainties about the data provided, or wish to provide further information, please use the space for “Additional Comments” at the bottom of this worksheet.
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Refrigerant (including that recovered from compressor oil)	CFC-12
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HCFC-22
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-134a
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
Foam-Blowing Agent*	CFC-11
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HCFC-141b
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-134a
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-245fa
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
Used Oil	Recycled			(gal)
Used Oil	Disposed			(gal)
Metal	Ferrous Metal Recycled			(lb)
Metal	Non-Ferrous Metal Recycled			(lb)
Plastic	Recycled			(lb)
PCB-Containing Capacitors	Destroyed			(# of capacitors)
Mercury-Containing Components	Recycled			(# of components)
Mercury-Containing Components	Disposed			(# of components)
*Foam-blowing agent typically represents only 10% of the total foam weight.
C. Energy Savings
Please complete the table below if your program provides an incentive (e.g., financial) to encourage the disposal (i.e., without replacement) of old, working refrigerated appliances.

Average Number of Remaining Years of Useful Life		Source: Department of Energy (DOE). 2009.Technical Support Document for the Final Rule on Residential Refrigerators, Refrigerator-Freezers and Freezers. Available online at www1.eere.energy.gov/buildings/appliance_standards/pdfs/refrig_finalrule_tsd.pdf
Average Energy Consumed/Year/Unit (kWh)
Average Energy Cost for Residential Consumers ($/kWh) [please provide the average cost during the current program period]

Additional Comments:







Revised 1/2016

Sheet 6: Step 3-Air-Conditioning Units



Step 3: Activity Data on Air-Conditioning Units					MM/DD/YYYY	to	MM/DD/YYYY
Instructions: All partners should complete Tables A and B. If your program provides an incentive (e.g., financial) to encourage the disposal of old, working refrigerated appliances, please also complete Table C. When populating cells, please use the units provided; do not add text to specify units. This form only recognizes numbers.
A. Units Processed
Please complete the gray cells below. Enter the total number of units processed by your program by refrigerant type in column D. Specify the number of units processed with refrigerant recovery in cells E11 to E14. Also, provide the average age of appliances collected (cell D9), and whether the information on refrigerant types is based on assumptions or data (cells F11 to F14). If any of the units reported in column D were jointly processed/administered with another RAD Utility, Retailer, Manufacturer, or State Partner, please indicate the number of these units in Step 4 - Units Jointly Processed; the units reported in this table should be inclusive of the units reported in Step 4. If you wish to provide additional information (e.g., regarding types of refrigerants or insulating materials not listed below) or highlight uncertainties in your reporting, please do so in the “Comments” box.

Total Number of Units Processed
Average Age of Appliances Collected (yrs)
Refrigerant Type	Total Number of Units Processed	Number of Units Processed with Refrigerant Recovery	Refrigerant Type Based On:	Comments:
HCFC-22
R-407C
R-410A
Other
Total	0	0

B. Fate and Quantity of Substances Recovered

Please complete the table below to provide the total amount of appliance components recovered by your program during the current reporting period. If any substances recovered during the current reporting period are currently in storage, please report on the intended fate of the substance (e.g., stockpiling with intent to reclaim/destroy). Refer back to the Instructions for Use for definitions of the fates for each component. For any fields that do not apply to your program, please enter "0" under "Total Amount" in column F. For every non-zero value entered in column F, indicate whether the quantity specified is based on actual measurements or on assumptions by selecting the appropriate option in column H. If you wish to clarify uncertainties about the data provided, or wish to provide further information, please use the space for “Additional Comments” at the bottom of this worksheet.
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Refrigerant (including that recovered from compressor oil)	HCFC-22
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	R-407C
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	R-410A
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
Used Oil	Recycled			(gal)
Used Oil	Disposed			(gal)
Metal	Ferrous Metal Recycled			(lb)
Metal	Non-Ferrous Metal Recycled			(lb)
Plastic	Recycled			(lb)
PCB-Containing Capacitors	Destroyed			(# of capacitors)

C. Energy Savings
Please complete the table below if your program provides an incentive (e.g., financial) to encourage the disposal (i.e., without replacement) of old, working refrigerated appliances. The estimates provided should be consistent with that specified in your jurisdiction's deemed savings database, technical reference manual (TRM), or third-party ARP evaluation, as appropriate.

Average Number of Remaining Years of Useful Life
Average Energy Consumed/Year/Unit (kWh)
Average Energy Cost for Residential Consumers ($/kWh) [please provide the average cost during the current program period]

Additional Comments:







Revised 1/2016

Sheet 7: Step 3-Dehumidifiers



MM/DD/YYYY	to	MM/DD/YYYY
Instructions: All partners should complete Tables A and B. If your program provides an incentive (e.g., financial) to encourage the disposal of old, working refrigerated appliances, please also complete Table C. When populating cells, please use the units provided; do not add text to specify units. This form only recognizes numbers.
A. Units Processed
Please complete the gray cells below. Enter the total number of units processed by your program by refrigerant type in column D. Specify the number of units processed with refrigerant recovery in cells E11 to E16. Also, provide the average age of appliances collected (cell D9), and whether the information on refrigerant types is based on assumptions or data (cells F11 to F16). If any of the units reported in column D were jointly processed/administered with another RAD Utility, Retailer, Manufacturer, or State Partner, please indicate the number of these units in Step 4 - Units Jointly Processed; the units reported in this table should be inclusive of the units reported in Step 4. If you wish to provide additional information (e.g., regarding types of refrigerants or insulating materials not listed below) or highlight uncertainties in your reporting, please do so in the “Comments” box.

Total Number of Units Processed
Average Age of Appliances Collected (yrs)
Refrigerant Type	Total Number of Units Processed	Number of Units Processed with Refrigerant Recovery	Refrigerant Type Based On:	Comments:
CFC-12
HCFC-22
HFC-134a
R-500
R-410A
Other
Total	0	0

B. Fate and Quantity of Substances Recovered

Please complete the table below to provide the total amount of appliance components recovered by your program during the current reporting period. If any substances recovered during the current reporting period are currently in storage, please report on the intended fate of the substance (e.g., stockpiling with intent to reclaim/destroy). Refer back to the Instructions for Use for definitions of the fates for each component. For any fields that do not apply to your program, please enter "0" under "Total Amount" in column F. For every non-zero value entered in column F, indicate whether the quantity specified is based on actual measurements or on assumptions by selecting the appropriate option in column H. If you wish to clarify uncertainties about the data provided, or wish to provide further information, please use the space for “Additional Comments” at the bottom of this worksheet.
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Appliance Component	Fate of Component		Total Amount		Total Amount Based On:
Refrigerant (including that recovered from compressor oil)	CFC-12
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HCFC-22
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	HFC-134a
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	R-500
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
	R-410A
	Reclaimed			(lb)
	Stockpiling with Intent to Reclaim			(lb)
	Destroyed			(lb)
	Stockpiling with Intent to Destroy			(lb)
Used Oil	Recycled			(gal)
Used Oil	Disposed			(gal)
Metal	Ferrous Metal Recycled			(lb)
Metal	Non-Ferrous Metal Recycled			(lb)
Plastic	Recycled			(lb)
PCB-Containing Capacitors	Destroyed			(# of capacitors)

C. Energy Savings
Please complete the table below if your program provides an incentive (e.g., financial) to encourage the disposal (i.e., without replacement) of old, working refrigerated appliances. The estimates provided should be consistent with that specified in your jurisdiction's deemed savings database, technical reference manual (TRM), or third-party ARP evaluation, as appropriate.

Average Number of Remaining Years of Useful Life
Average Energy Consumed/Year/Unit (kWh)
Average Energy Cost for Residential Consumers ($/kWh) [please provide the average cost during the current program period]

Additional Comments:







Revised 1/2016

Sheet 8: Step 4-Units Jointly Processed



to	MM/DD/YYYY

Instructions: Complete this page if you partner with another RAD Utility, Retailer, Manufacturer, or State Partner to jointly process/administer any of your units. The number of units should be reported by partner, in columns D through H. When reporting the units by refrigerant type and blowing agent type, report only the units processed with refrigerant recovery and foam recovery, respectively. If your program jointly processed units with more than five partners, please click on the button below to add additional partner columns. This information is important for ensuring that no units are double-counted when calculating aggregate nationwide benefits achieved by RAD partners. When populating cells, please use the units provided; do not add text to specify units. If you wish to provide further information, please use the space for "Additional Comments" at the bottom of this worksheet.



Refrigerators	Partner #1	Partner #2
Name of RAD Partner that Jointly Processes Your Units						Total Number Jointly Processed
Total Number of Units Jointly Processed						0
Number of Units Jointly Processed with Refrigerant Recovery
CFC-12						0
HFC-134a						0
Other						0
Total	0	0	0	0	0	0
Number of Units Jointly Processed with Foam Recovery
CFC-11 Blowing Agent						0
HCFC-141b Blowing Agent						0
HFC-134a Blowing Agent						0
HFC-245fa Blowing Agent						0
Cyclopentane Blowing Agent						0
Fiberglass						0
Other						0
Total	0	0	0	0	0	0
Stand-Alone Freezers	Partner #1	Partner #2	Partner #3	Partner #4	Partner #5
Name of RAD Partner that Jointly Processes Your Units						Total Number Jointly Processed
Total Number of Units Jointly Processed						0
Number of Units Jointly Processed with Refrigerant Recovery
CFC-12						0
HCFC-22						0
HFC-134a						0
Other						0
Total	0	0	0	0	0	0
Number of Units Jointly Processed with Foam Recovery
CFC-11 Blowing Agent						0
HCFC-141b Blowing Agent						0
HFC-134a Blowing Agent						0
HFC-245fa Blowing Agent						0
Cyclopentane Blowing Agent						0
Fiberglass						0
Other						0
Total	0	0	0	0	0	0
Air-Conditioning Units	Partner #1	Partner #2	Partner #3	Partner #4	Partner #5
Name of RAD Partner that Jointly Processes Your Units						Total Number Jointly Processed
Total Number of Units Jointly Processed						0
Number of Units Jointly Processed with Refrigerant Recovery
HCFC-22						0
R-407C						0
R-410A						0
Other						0
Total	0	0	0	0	0	0
Dehumidifiers	Partner #1	Partner #2	Partner #3	Partner #4	Partner #5
Name of RAD Partner that Jointly Processes Your Units						Total Number Jointly Processed
Total Number of Units Jointly Processed						0
Number of Units Jointly Processed with Refrigerant Recovery
CFC-12						0
HCFC-22						0
HFC-134a						0
R-500						0
R-410A						0
Other						0
Total	0	0	0	0	0	0



Additional Comments:







Revised 1/2016

Sheet 9: Step 5-QA_Input Data Summary




Instructions: Review the input data summarized in the table below to ensure that the data entered in the Step 3 worksheets are error-free. The table below presents the calculated average quantities of refrigerant, foam-blowing agent, and durable materials recovered per appliance and is self-populated based on the activity data reported in the Step 3 worksheet(s). The typical range reported by partners in previous years can be displayed in comments by holding your cursor over each cell, and should be used as guidance to identify potential reporting errors in the Step 3 worksheet(s).
Average Quantity Recovered Per Unit, Calculated Based on Reported Total Quantity and Number of Units Processed
	Appliance Type
	Refrigerators	Stand-Alone Freezers	Air-Conditioning Units	Dehumidifiers
Number of Units	0	0	0	0
Refrigerant (lb)*
CFC-12	0.2-0.5	0.1-0.5	NA	Average quantities not available based on previous partner reports.
HCFC-22	NA	0.4-0.6	0.5-1.0	0.4-0.6
HFC-134a	0.1-0.4	0.2-0.4	NA	0.3-0.5
R-500A	NA	NA	NA	Average quantities not available based on previous partner reports.
R-407C	NA	NA	Average quantities not available based on previous partner reports.	NA
R-410A	NA	NA	0.6	0.3
Average across all units
Foam-Blowing Agent (lb)**
CFC-11	0.6-1.0	0.6-1.0	NA	NA
HCFC-141b	0.6-1.2	0.6-1.0	NA	NA
HFC-134a	0.6-1.2	Average quantities not available based on previous partner reports.	NA	NA
HFC-245fa	0.6-1.2	1	NA	NA
Average across all units			NA	NA
Durable Materials
Used oil (gal)	0.06-0.08	0.06-0.08	0.1-0.4	0.05-0.4
Ferrous metals (lb)	120-140	125-140	65-75	18-28
Non-ferrous metals (lb)	5-7	5-7	10-15	4-7
Plastic (lb)	13-45	13-45	2-5	4-8
Glass (lb)	3-6	NA	NA	NA
Number of PCB-containing capacitors	0.0001-0.02	0.0-0.1	0.0-0.25	0.0-0.2
Number of Mercury-containing components	NA	0.1-0.5	NA	NA
*Average calculated based on reported number of units processed with refrigerant recovery.
**Average calculated based on reported number of units processed with foam recovery.

Revised 1/2016

Sheet 10: Step 5-Env Benefits

Instructions: No action is required. The tables below are for reference only and are self-populated based on the activity data reported in the Step 3 worksheet(s).

Emissions Avoided

The table below presents the cumulative avoided emissions of greenhouse gas and ozone depleting substances resulting from your program. It is calculated based on assumptions of destruction and reclamation efficiencies developed by the U.S. EPA.
Note: It is assumed that removing units from the electricity grid will only result in environmental benefits if your program offers an incentive to retire old, working appliances. In addition, the estimated ozone and greenhouse gas benefits associated with avoided releases of refrigerant and foam-blowing agent are subject to change as more information becomes available (e.g., regarding loss rates associated with various recovery technologies and practices, baseline emissions, global warming potentials [GWPs], etc.).

Appliance Component

Total Amount Prevented from Being Emitted

Greenhouse Gas (GHG) Emissions Avoided (MTCO2eq)a

Ozone Depleting Substances (ODS) Emissions Avoided (ODP-Weighted kg)b

(lb)

(kg)

Refrigerantc

CFC-12 Reclaimed

0.0

HCFC-22 Reclaimed

0.0

HFC-134a Reclaimed

0.0

R-500 Reclaimed

0.0

R-407C Reclaimed

0.0

R-410A Reclaimed

0.0

Reclaimed

0.0

CFC-12 Stockpiling with Intent to Reclaim

0.0

HCFC-22 Stockpiling with Intent to Reclaim

0.0

HFC-134a Stockpiling with Intent to Reclaim

0.0

R-500 Stockpiling with Intent to Reclaim

0.0

R-407C Stockpiling with Intent to Reclaim

0.0

R-410A Stockpiling with Intent to Reclaim

0.0

Stockpiling with Intent to Reclaim

0.0

CFC-12 Destroyed

0.0

HCFC-22 Destroyed

0.0

HFC-134a Destroyed

0.0

R-500 Destroyed

0.0

R-407C Destroyed

0.0

R-410A Destroyed

0.0

Destroyed

0.0

CFC-12 Stockpiling with Intent to Destroy

0.0

HCFC-22 Stockpiling with Intent to Destroy

0.0

HFC-134a Stockpiling with Intent to Destroy

0.0

R-500 Stockpiling with Intent to Destroy

0.0

R-407C Stockpiling with Intent to Destroy

0.0

R-410A Stockpiling with Intent to Destroy

0.0

Stockpiling with Intent to Destroy

0.0

Subtotal

0.0

Foam-Blowing Agentd

CFC-11 Reclaimed

0.0

HCFC-141b Reclaimed

0.0

HFC-245fa

HFC-134a Reclaimed

0.0

HFC-245fa

HFC-134a

HFC-245fa Reclaimed

0.0

HFC-134a

Reclaimed

0.0

CFC-11 Stockpiling with Intent to Reclaim

0.0

HCFC-141b Stockpiling with Intent to Reclaim

0.0

HFC-245fa

HFC-134a Stockpiling with Intent to Reclaim

0.0

HFC-245fa

HFC-134a

HFC-245fa Stockpiling with Intent to Reclaim

0.0

HFC-134a

Stockpiling with Intent to Reclaim

0.0

CFC-11 Destroyed

0.0

HCFC-141b Destroyed

0.0

HFC-245fa

HFC-134a Destroyed

0.0

HFC-245fa

HFC-134a

HFC-245fa Destroyed

0.0

HFC-134a

Destroyed

0.0

CFC-11 Stockpiling with Intent to Destroy

0.0

HCFC-141b Stockpiling with Intent to Destroy

0.0

HFC-245fa

HFC-134a Stockpiling with Intent to Destroy

0.0

HFC-245fa

HFC-134a

HFC-245fa Stockpiling with Intent to Destroy

0.0

HFC-134a

Stockpiling with Intent to Destroy

0.0

Subtotal

0.0

Durable Materials

Ferrous Metal Recycled

0.0

Non-Ferrous Metal Recycled

0.0

Plastic Recycled

0.0

Glass Recycled

0.0

Subtotal

0.0

Removing Units from the Grid

Subtotal Energy Savings

0.0

TOTAL

0.0

NA = not applicable.

aGWP = global warming potential; the ratio of heat trapped by one unit mass of a gas to that of one unit mass of carbon dioxide. Calculations are based on the direct 100-year GWPs provided in the Intergovernmental Panel on Climate Change Fourth Assessment Report: Climate Change 2007.

bODP = ozone depleting potential; the ratio of calculated ozone column change for each mass unit of a gas emitted into the atmosphere relative to the calculated depletion for the reference gas CFC-11 (ODP = 1.0). For calculation purposes, ODPs defined in the Montreal Protocol are used.

cRefrigerant assumptions: destruction results in emissions of 0.01% (assuming destruction occurs using a TEAP-approved technology, with DRE of 99.99%); the reclamation process results in emissions of 1.5%.

dFoam-blowing agent assumptions: destruction results in emissions of 0.09% (assuming destruction occurs in a municipal solid waste incinerator or waste-to-energy facility with a DRE of 99.91%); the reclamation process results in emissions of 1.5%; baseline emissions are assumed to be 100% (i.e., no anaerobic degradation of CFC blowing agent in landfills is assumed).

Hazardous Materials Recovered

The table below presents the amounts of hazardous materials avoided from being released to the environment as a result of your program.

Properly Recovered Component

Total Amount

Used Oil Recycled or Properly Disposed (gal)

0.0

PCB-Containing Capacitors

Number Destroyed

Mercury-Containing Components

Number Recycled

Number Disposed

Revised 1/2016

Sheet 11: Step 5-Energy Impacts



Step 5: Summary of Program's Gross Energy Impacts from Removal of Old Units
*(Current Period Dollars)*
Instructions: No action is required. The table below is for reference only and is self-populated if data are entered in the Step 3 worksheet Energy Savings tables. Data in the table below apply to the current reporting period.

	MM/DD/YYYY	to	MM/DD/YYYY

Appliance Type	Total # of Units Processed		Total Saved Energy (kWh)	Total Savings to Residential Consumers ($)
Refrigerators	0		0.0	$0.00
Stand Alone Freezers	0		0.0	$0.00
Air-Conditioning Units	0		0.0	$0.00
Dehumidifiers	0		0.0	$0.00
Total	0		0.0	$0.00

Revised 1/2016

Sheet 12: Step 6-Partner Feedback



	Step 6: Partner Feedback
	Instructions: The U.S. EPA is interested in learning more about your program and receiving feedback on the RAD Program. Please take a moment to answer the following three questions.


	Question #1
	As part of your appliance recycling program, have you undertaken any innovative activities during the year to promote the safe disposal of appliances and/or raise consumer awareness? Please describe. You may also send any photos along with this reporting form at the time of submission.


	Question #2
	As a RAD Partner, what are the greatest benefits that you’ve realized through the Program?




	Question #3
	Do you have any suggestions for how the RAD Program can be improved?





	Revised 1/2016

Sheet 13: Step 7-Confirmation




Step 7: Confirmation
Instructions: Prior to submitting this form, please review all Step 3 worksheet(s) and Step 5 QA Input Data Summary worksheet and confirm below that the information is accurate, to the best of your knowledge. Your name and date must be entered into the cells below in order for this form to be considered complete.

I certify that I have personally examined and am familiar with the information submitted in this report, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.




Name	Date	MM/DD/YYYY


Revised 1/2016

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