5900-255 WMTLs SMTLs Data Entry

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Overview

W_SMTL Submission
W_SMTL PT Submission

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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

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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: