DOE F 220.57 Refrigerated Beverage Vending Machines Appendix B

---

Overview

Certification
Input
Product Group Codes

---

Sheet 1: Certification

OMB Control Number: 1910-1400 (Expiration Date: XXXXXX XX, XXXX)

Version 5.4

DOE F 220.57

Refrigerated Bottled or Canned Beverage Vending Machines - Appendix B

Product Type:

Refrigerated Bottled or Canned Beverage Vending Machines - Appendix B

Status of This Certification Sheet

No Data

5.4

Overall Status of Template

No Data

Click here for instructions for completing this form

Each Importer and U.S. Manufacturer is legally required to certify the compliance of the products it imports, produces, assembles or manufactures. This party is the "Certifier" on this form. This certification may be submitted by the Importer or U.S. manufacturer or by a Third Party Representative. This party is the "Submitter" on this form.

Certifier - Party Legally Obligated to Certify Compliance

Submitter - Party Submitting This Report

The party responsible for certification is (select one only):

The party submitting this report is (select one only):

Please enter required data

Please enter required data

Certifier Contact Information

Third Party Representative Contact Information, if Applicable

Full Legal Name of Individual

Please enter required data

Full Legal Name of Individual

Please enter required data

Full Legal Name of Company

Please enter required data

Full Legal Name of Company

Please enter required data

Complete Company Mailing Address

Please enter required data

Complete Company Mailing Address

Please enter required data

Phone Number

Please enter required data

Phone Number

Please enter required data

Email Address

Please enter required data

Email Address

Please enter required data

Compliance Statement

Select one of the options for 'Submitter - Party Submitting This Report' above

Submitter Signature (Type your Full Legal Name)

Please enter required data

Date (MM/DD/YYYY)

Please enter required data

OMB Control Number: 1910-1400 (Expiration Date: XXXXXX XX, XXXX)

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 35 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

Refrigerated Bottled or Canned Beverage Vending Machines - Appendix B	Refrigerated Bottled or Canned Beverage Vending Machines - Appendix B							Version 5.4		· 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 far right.
5.4
	Status of This Input Sheet		No Data	Overall Status of Template		No Data
	Certification Report			Click here for instructions for completing this form																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	Manufacturer	Brand Name(s)	Basic Model Number	Individual Model Number Covered by Basic Model	Action	Product Group Code	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	Daily Energy Consumption (kWh/day)	Refrigerated Volume (V) (cubic feet)	Was Testing Conducted with Payment Mechanism in Place and Operational?	Lowest Application Product Temperature, If Applicable (Degrees F)	Was Testing Conducted Using An Accessory Low Power Mode?	Was Represented Daily Energy Consumption Based On The Presence Of A Refrigeration Low Power Mode?		Manufacturer Status	Brand Name(s) Status	Basic Model Number Status	Individual Model Number Covered by Basic Model Status	Action Status	Product Group Code 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	Daily Energy Consumption (kWh/day) Status	Refrigerated Volume (V) (cubic feet) Status	Was Testing Conducted with Payment Mechanism in Place and Operational? Status	Lowest Application Product Temperature, If Applicable (Degrees F) Status	Was Testing Conducted Using An Accessory Low Power Mode? Status	Was Represented Daily Energy Consumption Based On The Presence Of A Refrigeration Low Power Mode? 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

---

Sheet 3: Product Group Codes

The following is a description of each product group code:
Product Group Code	Product Group Code Description
1	Class A - A refrigerated bottled or canned beverage vending machine that is not a combination vending machine and in which 25 percent or more of the surface area on the front side of the beverage vending machine is transparent.
2	Class B - A refrigerated bottled or canned beverage vending machine that is not considered to be Class A and is not a combination vending machine.
3	Combination A - A combination vending machine where 25 percent or more of the surface area on the front side of the beverage vending machine is transparent.
4	Combination B - A combination vending machine that is not considered to be Combination A.