5900-67 Qualified Product Information Form for Hot Food Holding

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

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Qualified Product Information Form for Hot Food Holding Cabinets

Office of Atmospheric Programs

­ENERGY STAR^® product information form for use by ENERGY STAR hot food holding cabinet partners

(Companies who have joined ENERGY STAR for hot food holding cabinets by signing a Partnership Agreement)

You may use this form to report only those products that are sold under the company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join ENERGY STAR and report its own products. Information from this form will be added to the list of ENERGY STAR qualified hot food holding cabinets. Please copy this form and return one for each qualifying product model to the address provided below.

Company Name:______________________________ Product Contact Information

(As listed in Partnership Agreement) (For public requesting product information)

Name: ___________________________

Tel:___________________

Fax:___________________

E-mail: ___________________________

Please provide information on the tested model ONLY and complete all the fields below. If tested model is being submitted to represent a family of products then manufacturer must attach to this QPI form a list of additional model numbers that they wish to qualify within that family along with individual equipment specification sheets.

Brand Name/ Manufacturer	Model Name & Number	Door Type*	Wall Type*	Internal Volume (ft3)**	Energy Usage (watts)	Idle Energy Rate (watts/ft3)

* Please indicate glass or solid.

** Calculated by: interior height x interior width x interior depth

Number of doors: __________

Date model available for purchase: _________________

Tested By: (Name of Independent Testing Firm or Self-Tested) _____________Date Tested: _____________

Note: testing must be done in accordance with ASTM Standard F2140-01.

Labeling Requirements

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 Hot Food Holding Cabinets. These requirements include:

 On the product  In product literature  On Internet site

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

Please submit your completed Qualified Product Information Forms one of the following ways:

E-mail QPI forms to ENERGY STAR for Commercial Hot Food Holding Cabinets at commercialfoodservice@icfi.com.

Fax QPI forms to ENERGY STAR for Commercial Hot Food Holding Cabinets at (202) 862-1144.

US Mail/Overnight/Express QPI forms to: ENERGY for Commercial Hot Food Holding Cabinets, 1725 Eye St. 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.

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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. 5900-67