Att 3. Refrigerant Removal Verification Statement.pdf
PDF 404 KB Posted
- Solicitation number
- SP451026Q1037
- Issued by
-
Defense Logistics Agency
About this file
This is a DLA Disposition Services Form 2016 template for documenting refrigerant removal verification in compliance with federal environmental regulations.
The form serves as an official certification statement that refrigerant has been removed from appliances or equipment in accordance with the Clean Air Act Amendments of 1990, Section 608, and U.S. EPA Regulations at 40 CFR 82.156. The form requires the technician who removed the refrigerant to provide their name, street address, city, state, and zip code, along with the date the refrigerant was removed. For each item processed, the form requires an item description (using common names or including serial numbers as applicable), item quantity, and a single DTID number (Defense Reutilization and Marketing Office identification number) that must be permanently marked on each item. The person turning in the appliance(s) must print their name and provide a signature. The form notes that common item names are acceptable for the item description field, and a single form can cover multiple items as long as each item is permanently marked with the DTID number. Recipients must retain a copy of the completed certificate for three years from the date of receipt along with the corresponding DTID documentation.
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Other files
| File | Type | Posted |
|---|---|---|
| Att 5. 26Q1037_Q&A_27AUG206.xlsx | XLSX spreadsheet | |
| Att 1. 26Q1037_PWS.pdf | ||
| Att 2. 26Q1037_Price Schedule.xlsx | XLSX spreadsheet | |
| Att 4. SP451026Q1021_Past Performance Q.doc | DOC document |
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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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File details come from the government source that posted it. Updated .