DOE New Traffic Signal Ped Modules

Compliance Statement Energy/Water Conservation Standards for Appliances

Copy of TEMPLATE_Traffic_Signal_Ped_Modules_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

Traffic Signal Modules and Pedestrian Modules Product Type: Traffic Signal Modules and Pedestrian Modules 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

Traffic Signal Modules and Pedestrian Modules Product Type:
Traffic Signal Modules and Pedestrian Modules
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". 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 Maximum Wattage at 74 Degrees C (watts) Nominal Wattage at 25 Degrees C (watts)
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 Maximum Wattage at 74 Degrees C (watts) Status Nominal Wattage at 25 Degrees C (watts) Status Status
1

































2

































3

































4

































5

































6

































7

































8

































9

































10

































11

































12

































13

































14

































15

































16

































17

































18

































19

































20

































21

































22

































23

































24

































25

































26

































27

































28

































29

































30

































31

































32

































33

































34

































35

































36

































37

































38

































39

































40

































41

































42

































43

































44

































45

































46

































47

































48

































49

































50

































51

































52

































53

































54

































55

































56

































57

































58

































59

































60

































61

































62

































63

































64

































65

































66

































67

































68

































69

































70

































71

































72

































73

































74

































75

































76

































77

































78

































79

































80

































81

































82

































83

































84

































85

































86

































87

































88

































89

































90

































91

































92

































93

































94

































95

































96

































97

































98

































99

































100

































101

































102

































103

































104

































105

































106

































107

































108

































109

































110

































111

































112

































113

































114

































115

































116

































117

































118

































119

































120

































121

































122

































123

































124

































125

































126

































127

































128

































129

































130

































131

































132

































133

































134

































135

































136

































137

































138

































139

































140

































141

































142

































143

































144

































145

































146

































147

































148

































149

































150

































151

































152

































153

































154

































155

































156

































157

































158

































159

































160

































161

































162

































163

































164

































165

































166

































167

































168

































169

































170

































171

































172

































173

































174

































175

































176

































177

































178

































179

































180

































181

































182

































183

































184

































185

































186

































187

































188

































189

































190

































191

































192

































193

































194

































195

































196

































197

































198

































199

































200

































201

































202

































203

































204

































205

































206

































207

































208

































209

































210

































211

































212

































213

































214

































215

































216

































217

































218

































219

































220

































221

































222

































223

































224

































225

































226

































227

































228

































229

































230

































231

































232

































233

































234

































235

































236

































237

































238

































239

































240

































241

































242

































243

































244

































245

































246

































247

































248

































249

































250

































251

































252

































253

































254

































255

































256

































257

































258

































259

































260

































261

































262

































263

































264

































265

































266

































267

































268

































269

































270

































271

































272

































273

































274

































275

































276

































277

































278

































279

































280

































281

































282

































283

































284

































285

































286

































287

































288

































289

































290

































291

































292

































293

































294

































295

































296

































297

































298

































299

































300

































301

































302

































303

































304

































305

































306

































307

































308

































309

































310

































311

































312

































313

































314

































315

































316

































317

































318

































319

































320

































321

































322

































323

































324

































325

































326

































327

































328

































329

































330

































331

































332

































333

































334

































335

































336

































337

































338

































339

































340

































341

































342

































343

































344

































345

































346

































347

































348

































349

































350

































351

































352

































353

































354

































355

































356

































357

































358

































359

































360

































361

































362

































363

































364

































365

































366

































367

































368

































369

































370

































371

































372

































373

































374

































375

































376

































377

































378

































379

































380

































381

































382

































383

































384

































385

































386

































387

































388

































389

































390

































391

































392

































393

































394

































395

































396

































397

































398

































399

































400

































401

































402

































403

































404

































405

































406

































407

































408

































409

































410

































411

































412

































413

































414

































415

































416

































417

































418

































419

































420

































421

































422

































423

































424

































425

































426

































427

































428

































429

































430

































431

































432

































433

































434

































435

































436

































437

































438

































439

































440

































441

































442

































443

































444

































445

































446

































447

































448

































449

































450

































451

































452

































453

































454

































455

































456

































457

































458

































459

































460

































461

































462

































463

































464

































465

































466

































467

































468

































469

































470

































471

































472

































473

































474

































475

































476

































477

































478

































479

































480

































481

































482

































483

































484

































485

































486

































487

































488

































489

































490

































491

































492

































493

































494

































495

































496

































497

































498

































499

































500

































501

































502

































503

































504

































505

































506

































507

































508

































509

































510

































511

































512

































513

































514

































515

































516

































517

































518

































519

































520

































521

































522

































523

































524

































525

































526

































527

































528

































529

































530

































531

































532

































533

































534

































535

































536

































537

































538

































539

































540

































541

































542

































543

































544

































545

































546

































547

































548

































549

































550

































551

































552

































553

































554

































555

































556

































557

































558

































559

































560

































561

































562

































563

































564

































565

































566

































567

































568

































569

































570

































571

































572

































573

































574

































575

































576

































577

































578

































579

































580

































581

































582

































583

































584

































585

































586

































587

































588

































589

































590

































591

































592

































593

































594

































595

































596

































597

































598

































599

































600

































601

































602

































603

































604

































605

































606

































607

































608

































609

































610

































611

































612

































613

































614

































615

































616

































617

































618

































619

































620

































621

































622

































623

































624

































625

































626

































627

































628

































629

































630

































631

































632

































633

































634

































635

































636

































637

































638

































639

































640

































641

































642

































643

































644

































645

































646

































647

































648

































649

































650

































651

































652

































653

































654

































655

































656

































657

































658

































659

































660

































661

































662

































663

































664

































665

































666

































667

































668

































669

































670

































671

































672

































673

































674

































675

































676

































677

































678

































679

































680

































681

































682

































683

































684

































685

































686

































687

































688

































689

































690

































691

































692

































693

































694

































695

































696

































697

































698

































699

































700

































701

































702

































703

































704

































705

































706

































707

































708

































709

































710

































711

































712

































713

































714

































715

































716

































717

































718

































719

































720

































721

































722

































723

































724

































725

































726

































727

































728

































729

































730

































731

































732

































733

































734

































735

































736

































737

































738

































739

































740

































741

































742

































743

































744

































745

































746

































747

































748

































749

































750

































751

































752

































753

































754

































755

































756

































757

































758

































759

































760

































761

































762

































763

































764

































765

































766

































767

































768

































769

































770

































771

































772

































773

































774

































775

































776

































777

































778

































779

































780

































781

































782

































783

































784

































785

































786

































787

































788

































789

































790

































791

































792

































793

































794

































795

































796

































797

































798

































799

































800

































801

































802

































803

































804

































805

































806

































807

































808

































809

































810

































811

































812

































813

































814

































815

































816

































817

































818

































819

































820

































821

































822

































823

































824

































825

































826

































827

































828

































829

































830

































831

































832

































833

































834

































835

































836

































837

































838

































839

































840

































841

































842

































843

































844

































845

































846

































847

































848

































849

































850

































851

































852

































853

































854

































855

































856

































857

































858

































859

































860

































861

































862

































863

































864

































865

































866

































867

































868

































869

































870

































871

































872

































873

































874

































875

































876

































877

































878

































879

































880

































881

































882

































883

































884

































885

































886

































887

































888

































889

































890

































891

































892

































893

































894

































895

































896

































897

































898

































899

































900

































901

































902

































903

































904

































905

































906

































907

































908

































909

































910

































911

































912

































913

































914

































915

































916

































917

































918

































919

































920

































921

































922

































923

































924

































925

































926

































927

































928

































929

































930

































931

































932

































933

































934

































935

































936

































937

































938

































939

































940

































941

































942

































943

































944

































945

































946

































947

































948

































949

































950

































951

































952

































953

































954

































955

































956

































957

































958

































959

































960

































961

































962

































963

































964

































965

































966

































967

































968

































969

































970

































971

































972

































973

































974

































975

































976

































977

































978

































979

































980

































981

































982

































983

































984

































985

































986

































987

































988

































989

































990

































991

































992

































993

































994

































995

































996

































997

































998

































999

































1000





































































Sheet 3: Product Description

The following is a description of each product class:


Product Class Product Class Description

Traffic Signal Module Type
1 12" Red Ball
2 8" Red Ball
3 12" Red Arrow
4 12" Green Ball
5 8" Green Ball
6 12" Green Arrow

Pedestrian Module Type
7 Combination Walking Man/Hand
8 Walking Man
9 Orange Hand
Other Other traffic signal modules or pedestrian modules of a type 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

Traffic Signal Modules and Pedestrian Modules
4.1
File Typeapplication/vnd.ms-excel
AuthorBruce Miller
Last Modified ByRoulech
File Modified2011-01-18
File Created2007-08-23

© 2024 OMB.report | Privacy Policy