Refrigerant Removal Verification Statement.pdf

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