OMB Control No. 2060-0528

Approval Expires 03/31/2011

Qualified Product Information Form for

New and Rebuilt Refrigerated Beverage Vending Machines

Office of Atmospheric Programs

ENERGY STAR® Qualified Product Information (QPI) Form for use by ENERGY STAR Refrigerated Beverage Vending Machines Partners (Companies who have joined ENERGY STAR for Refrigerated Beverage Vending Machines by signing the Partnership Agreement). Information from this form will be added to the list of ENERGY STAR Qualified Refrigerated Beverage Vending Machines on the ENERGY STAR Web site at www.energystar.gov.

For Rebuilt Machines: The “Rebuilt Model Number” provided below in Section IB must be distinct and representative of a particular model and rebuilding kit combination that has been tested for ENERGY STAR qualification. Partner may submit multiple component and/or rebuilding kit options for one vending machine model but each of these combinations must be supported by individual test results and represented by separate rebuilt model numbers. Partners will be responsible for providing separate QPI forms for each model and rebuilding kit combination.

Company Name:

(As listed in Partnership Agreement) Product Contact Information

(For public requesting product information)

Name:

Tel:

Fax:

Email:

I  Qualifying Model Information: Please provide the following information on the tested model ONLY and complete all the fields below.

Date model available for purchase:

A.  New Machines

Original Equipment Manufacturer (OEM) / Model Name / Model Number / Door Type* / Indoor Use Only (yes/no)** / Vendible Capacity^

B.  Rebuilt Machines (Note: the “Rebuilt Model Number” below must be representative of the individual machine and rebuilding kit combination, and must differ from the OEM nameplate model number.)

Original Equipment Manufacturer (OEM) / OEM Model Name/Number / Rebuilt Model Number / Door Type* / Indoor Use Only (yes/no)** / Vendible Capacity^

*Please indicate closed-front, glass front, live display, or other.

**Please indicate if this machine is designated for indoor use only.

^Expressed in number of full 12-ounce (355 ml) cans for machines capable of dispensing 12 oz (355 ml) cans. For all other machines, the standard product shall be that specified by the manufacturer as the standard product.

Identify Energy Saving Kit or Components (attach sheet if necessary): Partner is responsible for reporting the specific components and/or rebuilding kit used to qualify the rebuilt machine model listed in the table above.

Rebuilding Kit and Model Number:

OR

Component Type / Component OEM / Component Model Number

II  Energy Efficiency Performance

Model shipped with low power mode capability (required)?

Energy Consumption
(kWh/day)
Outdoor Conditions (90°/65% RH) / Indoor Conditions
(75°/45% RH)

Yes No

Type of low power control (s):

Note: Manufacturer may test and report at one or both of the conditions listed in the energy consumption table above depending on how the machine will be Listed in accordance with the UL Standard for Refrigerated Vending Machines, UL 541. The values provided in this table will be included in the qualifying products list, along with the testing conditions, on the ENERGY STAR Web site.

III  Testing Requirements

Tested by: (Name of Independent Testing Firm or Self Tested):

Date Tested:

Note: Testing must be done in accordance with current ASHRAE Standard 32.1-2004 Methods of Testing for Rating Vending Machines for Bottled, Canned, and Other Sealed Beverages.

IV  Labeling Requirements

By checking the items below, you are confirming that you have reviewed and will meet the labeling requirements outlined in the ENERGY STAR Version 2.0 Program Requirements for Refrigerated Beverage Vending Machines once this model has been approved by EPA for qualification. These requirements include:

On front of machine or on/next to nameplate In Product Literature On Internet Site

If answer to any of the above is no, explain why:

Please check one or more of the following international markets where these products are sold (if applicable):

Australia/New Zealand Canada EU Japan Mexico Taiwan

V Declaration:

By checking this box, I declare that the information submitted via this form is, to the best of my knowledge, accurate and associated with the products included for qualification in this submittal. I understand that the ENERGY STAR Program will associate all data in this submittal with the products listed in this submittal upon receipt. I understand that if any of the submitted information is found to be inaccurate, the products will be removed from the ENERGY STAR qualified products list. I understand that intentionally submitting false information to the U.S. government is a criminal violation of the False Statements Act, Title 18 U.S.C. section 1001.

Date:

VI Instructions for Submittal:

Please submit your completed QPI Forms in one of the following ways:

E-mail:

Fax: (202) 862-1144

US Mail/Overnight Express: 1725 Eye Street NW, Suite 1000, Washington, DC 20006

QPI forms must be accompanied by a lab report. Additional information about acceptable lab report formats may be found at www.energystar.gov/labreport.

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 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, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 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.

ENERGY STAR for Refrigerated Beverage Vending Machines, US EPA (Mail Code 6202J)

1200 Pennsylvania Ave., Washington, DC 20460 USA

EPA Form No.5900-62

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