5900-405 Small Can Form

OMB Control Number: 2060-0256

Expiration Date: MM/DD/YYYY

ENVIRONMENTAL PROTECTION AGENCY

PART 1: ESTABLISHMENT INFORMATION

Name of Establishment	Street
(Area Code) Telephone Number	City State Zip Code

EPA requires manufacturers of small cans of automotive refrigerant to keep records of test data and log forms that demonstrate compliance with the allowable leakage rate (40 CFR §82.154(c)(2)).

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The number and expiration date are displayed in the upper right corner of the form. The public reporting and recordkeeping burden for this collection of information is estimated to average 2 hours per year. 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 Avenue NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

PART 2: SMALL CAN TEST DATA FORM

Enforcement Lot ID:		Full:		Upright:		T= 73 F:
		Half full:		Inverted:		T= 130 F:

Date:		Date:
Can ID	Initial time (hour)	Initial weight (g)	Final time (hour)	Final weight (g)	Delta days	Delta weight (g)	Adjusted annual rate (g/yr)

Number of Samples:		Average Loss Rate:
Technician:		Standard Deviation:

Comments:

SMALL CAN TEST DATA FORM

PART 3: BALANCE DATA LOG FORM

Rec #	Date	Time	Proj.	Prot.	Tech.	QC Code	Can		Recorded Grams	Comment
							Type	ID#
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

EPA FORM 5900-405