Atachment 3 Refrigerant Removal Verification Statement.pdf
PDF 404 KB Posted
- Solicitation number
- SP4510-26-Q-1046
- Issued by
-
Defense Logistics Agency
About this file
This is a Refrigerant Removal Verification Statement form issued by DLA Disposition Services (Form 2016, June 2011) that certifies compliance with federal environmental regulations regarding refrigerant removal from equipment and appliances.
The form documents the removal of refrigerants from items in accordance with the Clean Air Act Amendments of 1990, Section 608, and U.S. EPA Regulations at 40 CFR 82.156. It requires the technician performing the removal to provide their name, street address, city, state, zip code, and the date of removal. For each item, the form captures the item description (using common names, with optional serial numbers), item quantity, and a single DTID (Disposition Transaction Identification) number. The person turning in the appliance(s) must print their name and provide a signature. The form allows for multiple items to be listed on a single form provided each item is permanently marked with the DTID number. Records must be retained for three years from the date of receipt along with the DTID. This is a template form used for federal property disposition and environmental compliance documentation.
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Text version
DLA DISPOSITION SERVICES FORM 2016, JUN 2011
REFRIGERANT REMOVAL VERIFICATION STATEMENT
(Prescribing Authority: 40 CFR 82.156(f)(2) & DoD 4160.21-M)
THE REFRIGERANT HAS BEEN REMOVED FROM THE ITEM(S) LISTED BELOW, IN COMPLIANCE WITH THE CLEAN AIR ACT AMENDMENTS OF 1990, SECTION 608, AND U.S. EPA REGULATIONS AT 40 CFR 82.156
Technician Who Removed
Refrigerant Street Address City State Zip Code Date
Removed Item Description* Item Qty
DTID #
(Enter one only) Total Item Qty
Printed Name of Person Turning-In Appliance(s) Signature of Person Turning-In Applicance(s)
NOTE: Retain copy of certificate for 3 years with the DTID from the date of receipt.
*Common item names may be used for "Item Description". Serial numbers or other specific descriptions may be included in the item description, but are not required. As long as the DTID number is permanently marked on each item, a single form similar to the one above will suffice.
DLA DISPOSITION SERVICES FORM 2016, JUN 2011
REFRIGERANT REMOVAL VERIFICATION STATEMENT
(Prescribing Authority: 40 CFR 82.156(f)(2) & DoD 4160.21-M) THE REFRIGERANT HAS BEEN REMOVED FROM THE ITEM(S) LISTED BELOW, IN COMPLIANCE WITH THE CLEAN AIR ACT AMENDMENTS OF 1990, SECTION 608, AND U.S. EPA REGULATIONS AT 40 CFR 82.156 Technician Who Removed Refrigerant Street Address City State Zip Code Date Removed Item Description* Item Qty NOTE: Retain copy of certificate for 3 years with the DTID from the date of receipt.
*Common item names may be used for "Item Description". Serial numbers or other specific descriptions may be included in the item description, but are not required. As long as the DTID number is permanently marked on each item, a single form similar to the one above will suffice.
8.2.1.3158.1.475346.466429
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