5900-255 WMTLs SMTLs Data Entry

EPA's ENERGY STAR Product Labeling (Renewal)

WMTLs_SMTLs_data_entry.xlsx

Application for AB, CB, Lab, and W/SMTL Recognition and Scope Expansion

OMB: 2060-0528

Document [xlsx]
Download: xlsx | pdf

Overview

W_SMTL Submission
W_SMTL PT Submission


Sheet 1: W_SMTL Submission











OMB Control No. 2060-0528
Expiration Date: 1/31/2022






























Application for Witnessed or Supervised Testing Laboratory (W/SMTL) Version 1.19















Instructions: This Data Entry Sheet shall be used to submit first-party laboratories to EPA for a certification body's Witnessed or Supervised
Manufacturer's Testing Laboratory Program (W/SMTL).Lighting categories which require Proficiency Testing (PT) are found on the second tab of this application. Completed forms should be sent to [email protected].
Laboratory Information



















Laboratory Name:





Laboratory Address













Address Line 1:





Address Line 2:





City:





State / Province:





Country:





Postal Code:





Laboratory Contact













First Name:





Last Name:





Job Title:





Email Address:





Telephone Number:
Ext:


















Laboratory Category (please select one, not both):
































Supervised




























Witnessed







































ENERGY STAR Manufacturing Partner Affiliated with Laboratory (please provide Org ID):



































Manufacturer name (if different from ENERGY STAR partner):




















Certification Body Supervising or Witnessing Laboratory:




















Describe any lab limitations here (be as descriptive as possible):


































This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0528). Responses to this collection of information are voluntary (Section103(g) of the Clean Air Act). 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 public reporting and recordkeeping burden for this collection of information is estimated to 4.7 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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.
EPA Form No. 5900-255





















Product Categories Testing (Select all that apply):





























Appliances













Clothes Dryers




Dishwashers





Clothes Washers





Refrigerators and/or Freezers





Commercial Clothes Washers





Optional: Connected Functionality




















Heating and Cooling













Boilers





Geothermal Heat Pumps





Central Air Conditioners and Air-Source Heat Pumps




Light Commercial HVAC





Commercial Packaged Boilers




Room Air Cleaners and Purifiers





Commercial Water Heaters




Room Air Conditioners





Connected Thermostats




Residential Water Heaters - Solar





Dehumidifiers




Residential Water Heaters - Non-Solar





Furnaces



























Electronics and Office Equipment













Audio/Video




Large Network Equipment





Computers




Set-top Boxes & Cable Boxes





Data Center Storage




Small Network Equipment





Displays




Telephony





Enterprise Servers




Televisions





Imaging Equipment




Uninterruptible Power Supplies



















Lighting and Fans













Lamps





Luminaires





Decorative Light Strings




Residential Ventilating Fans





Ceiling Fans











LED Package, Module or Array (IES LM-80-2008): please contact EPA before applying for LM-80 recognition




























Commercial Food Service













Commercial Coffee Brewers





Commercial Combination Ovens





Commercial Dishwashers





Commercial Convection Ovens





Commercial Fryers




Commercial Rack Ovens





Commercial Griddles




Commercial Refrigerators and Freezers





Commercial Hot Food Holding Cabinets




Commercial Steam Cookers





Commercial Ice Machines


























Home Building Materials













Storm Windows


























Other













Pool Pumps





Water Coolers





Vending Machines




Lab-grade Refrigerators/Freezers





Electrical Vehicle Supply Equipment








EPA Form No. 5900-255















Sheet 2: W_SMTL PT Submission

Application for Witnessed or Supervised Manufacturers' Testing Laboratory (W/SMTL) requiring Proficiency Testing (IES LM-79-08)
W/SMTL Lighting Laboratory Information Version 1.19
















Laboratory Name:
















Laboratory Address:










Address Line 1




Address Line 2




City




State / Province




Country




Postal Code












Laboratory Contact:














First Name




Last Name




Job Title




Email Address




Telephone Number
Ext.












Laboratory Category:

























Supervised




















Witnessed


















ENERGY STAR Manufacturing Partner Affiliated with Laboratory:




























Manufacturer name (if different from ENERGY STAR partner):




























Certification Body Supervising or Witnessing Laboratory:




























Product Categories Testing (check all that apply):


























Lamps: Solid State LED Lamps (Directional)






















Lamps: Solid State LED Lamps (Omnidirectional and Decorative)






















Luminaires: Solid State (Non-directional and subcomponents)






















Luminaires: Solid State (Directional)























































Proficiency Testing Checklist












EPA-recognized certification bodies (CBs) should complete this checklist and submit it to [email protected] as part of the application for laboratories seeking EPA recognition within the CB's W/SMTL program for ENERGY STAR lighting product categories that require proficiency testing to IES LM-79-08: ILL Omnidirectional/Directional and Decorative, Luminaires - Solid State (Directional) and Solid State (Non-directional and subcomponents) available once LM-82 is published, and Lamps, once released.












1.


Laboratory has successfully completed NIST Proficiency Testing




2.


Date Laboratory completed NIST Proficiency Testing:























If Laboratory has not completed NIST Proficiency Testing, please complete the following:












3.


Laboratory has registered with NIST for Proficiency Testing.




4.


Date of Registration:




























5.


Laboratory has participated in Correlation Testing Program with an EPA-recognized laboratory for that product category.
















6.


Name and Organization ID of EPA-recognized laboratory used for Correlation Testing:























7.


Date Correlation Testing Started:





























8.


Date Correlation Testing Data Submitted to CB:





























9.


The CB has reviewed and accepted the results of Correlation Testing




10.


Expiration of Correlation Testing Data (6 months from completion of testing)










Round 1:









Round 2:









Round 3:





















Note: Extensions beyond Round 3 require approval from EPA


















11.


Date NIST Proficiency Testing Successfully Completed









































Name of CB:





ICF Initials:
Signature of CB contact:







Date of Signature:





ICF Date:













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