DOE New Self Cont Comm Refrig

Compliance Statement Energy/Water Conservation Standards for Appliances

Copy of TEMPLATE_Self-Cont_Comm_Refrig_Refrig-Freezer_Freezer_v4 1.xls

Compliance Statement Energy/Water Conservation Standards for Appliances

OMB: 1910-1400

Document [xlsx]
Download: xlsx | pdf

Overview

Certification
Input
Product Description
Instructions


Sheet 1: Certification

Commercial Packaged Boilers Product Type: Commercial Packaged Boilers Version 4.1
4.1




Status of This Certification Sheet No Data






Overall Status of Template No Data





Submitter Information


I am a(n) (check one only):





Please enter required data



The third-party representative includes industry organizations submitting on behalf of their members, foreign manufacturers who do not import and are submitting on behalf of their importers, private labelers submitting on behalf of an importer or domestic manufacturers, third-party testing organizations submitting on behalf of a manufacturer, etc.





Submitter Information (Required for all submissions):






Company Name:
Please enter required data

Company Address:
Please enter required data

Contact Name:
Please enter required data

Contact Telephone Number:
Please enter required data

Contact Fax Number:
Please enter required data

Contact email address:
Please enter required data

For importers, the U.S. Customs and Border Protection importer identification number (OPTIONAL):






Third Party-Representatives (If Submitter is not a Third-Party Representative, skip to Certification


If the submitter is a third-party representative, provide the following information on each company on whose behalf you are certifying. Note: Please complete an additional template if you are certifying on behalf of more than five companies.





If you are a Third-Party Representative, for how many companies on whose behalf are you certifying? (Maximum of 5)










1. Company Name:


Company Address:


Responsible Person at Company:


Telephone Number:


Fax Number:


Email Address:






Select all that apply (at least one):










For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):






For Private Labeler - Provide all of the brand name(s):










2. Company Name:


Company Address:


Responsible Person at Company:


Telephone Number:


Fax Number:


Email Address:






Select all that apply (at least one):










For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):






For Private Labeler - Provide all of the brand name(s):










3. Company Name:


Company Address:


Responsible Person at Company:


Telephone Number:


Fax Number:


Email Address:






Select all that apply (at least one):










For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):






For Private Labeler - Provide all of the brand name(s):










4. Company Name:


Company Address:


Responsible Person at Company:


Telephone Number:


Fax Number:


Email Address:






Select all that apply (at least one):










For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):






For Private Labeler - Provide all of the brand name(s):










5. Company Name:


Company Address:


Responsible Person at Company:


Telephone Number:


Fax Number:


Email Address:






Select all that apply (at least one):










For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):






For Private Labeler - Provide all of the brand name(s):






Certification


Compliance Statement


SELECT SUBMITTER TYPE AT THE TOP OF THIS WORKSHEET





Type your full name to signify compliance (required):
Please enter required data

Enter your email address (required):
Please enter required data

Date (MM/DD/YYYY) (required):
Please enter required data









OMB Control Number: 1910-1400


OMB Form Number: None






Paperwork Reduction Act Statement


OMB Burden Disclosure Statement






This data is being collected for manufacturers to certify compliance to DOE's energy conservation, water conservation, or design standards. The data you supply will be used by the Department to monitor compliance with the energy conservation, water conservation, and design standards and testing requirements for the consumer products and commercial and industrial equipment mandated by the Energy Policy and Conservation Act, as amended.

Public reporting burden for this collection of information is estimated to average 20 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project (1910-1400), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-1400), Washington, DC 20503.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number.

Submission of this data is mandatory.

Sheet 2: Input

Commercial Packaged Boilers Product Type:
Commercial Packaged Boilers
Version 4.1



























4.1




































Status of This Input Sheet No Data
Overall Status of Template No Data
































































Certification Report



























· Please enter your data in the columns shaded in gray below, using a separate line for each model.
· Click on the column heading for instructions on how to complete cells in that column.
· Cells highlighted in yellow indicate an "Error." "Error" means that information is missing or there is an issue with the entry.
· If the "Status" for a row is "Error," you can see an explanation in the columns to the right of the Status column.
· Reports submitted with errors cannot be processed and will be returned for resubmission.











The cells below provide an explanation for "Errors". The cells below provide an explanation for "Errors". The cells below provide an explanation for "Errors". The cells below provide an explanation for "Errors". The cells below provide an explanation for "Errors".










































































Line No. Status Manu-facturer For Third-Party Representatives, Company Number From Certification Sheet Brand Name(s) Basic Model Number Individual Model Number Covered by Basic Model Action Product Class Explanation of 'Other' Product Class Sample Size (Number of Units Tested) Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements? Date of Test Procedure Waiver, if Applicable Is the Certification based upon any Exception Relief from an Applicable Standard by DOE's Office of Hearing and Appeals? Date of Exception Relief, if Applicable Is Certification based on an Alternate Way of Determining Measures of Energy Conservation? Combustion Efficiency (%) Maximum Rated Input Capacity (Btu/h) Draft Type (For Gas-Fired Steam Commercial Packaged Boilers)
Manu-facturer Status For Third-Party Representatives, Company Number From Certification Sheet Status Brand Name(s) Status Basic Model Number Status Individual Model Number Covered by Basic Model Status Action Status Product Class Status Explanation of 'Other' Product Class Status Sample Size (Number of Units Tested) Status Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements? Status Date of Test Procedure Waiver, if Applicable Status Is the Certification based upon any Exception Relief from an Applicable Standard by DOE's Office of Hearing and Appeals? Status Date of Exception Relief, if Applicable Status Is Certification based on an Alternate Way of Determining Measures of Energy Conservation? Status Combustion Efficiency (%) Status Maximum Rated Input Capacity (Btu/h) Status Draft Type (For Gas-Fired Steam Commercial Packaged Boilers) Status
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Sheet 3: Product Description

The following is a description of each product class:


Product Class Product Class Description
1 Gas-Fired Hot Water Commercial Packaged Boilers with an Input Capacity Greater than or Equal to 300,000 Btu/h and Less than or Equal to 2,500,000 Btu/h
2 Gas-Fired Hot Water Commercial Packaged Boilers with an Input Capacity of Greater Than 2,500,000 Btu/h
3 Oil-Fired Hot Water Commercial Packaged Boilers with an Input Capacity Greater than or Equal to 300,000 Btu/h and Less than or Equal to 2,500,000 Btu/h
4 Oil-Fired Hot Water Commercial Packaged Boilers with an Input Capacity of Greater Than 2,500,000 Btu/h
5 Gas-Fired (all except natural draft) Steam Commercial Packaged Boilers with an Input Capacity Greater Than or Equal to 300,000 Btu/h and Less than 2,500,000 Btu/h
6 Gas-Fired (all except natural draft) Steam Commercial Packaged Boilers with an Input Capacity of Greater Than 2,500,000 Btu/h
7 Gas-Fired, Natural Draft, Steam Commercial Packaged Boilers with an Input Capacity Greater than or Equal to 300,000 Btu/h and Less than 2,500,000 Btu/h
8 Gas-Fired, Natural Draft, Steam Commercial Packaged Boilers with an Input Capacity of Greater Than 2,500,000 Btu/h
9 Oil-Fired Steam Commercial Packaged Boilers with an Input Capacity Greater than or Equal to 300,000 Btu/h and Less than 2,500,000 Btu/h
10 Oil-Fired Steam Commercial Packaged Boilers with an Input Capacity of Greater Than 2,500,000 Btu/h
Other Other commercial gas-fired or oil-fired warm air furnaces or packaged boilers not listed above (if you enter "Other", you must provide a rationale in the 'Explanation of "Other" Product Class' column on the "Input" sheet).

Sheet 4: Instructions

Commercial Packaged Boilers
4.1
File Typeapplication/vnd.ms-excel
AuthorBruce Miller
Last Modified ByRoulech
File Modified2011-01-18
File Created2007-08-23

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