Form 5900-405 Small Can Test Data Form

OMB Control Number: 2060-0256

Expiration Date: MM/DD/YYYY

ENVIRONMENTAL PROTECTION AGENCY

EPA requires manufacturers of small cans of automotive refrigerant to keep records of test data and log forms that demonstrate compliance with the allowable leakage rate (40 CFR §82.154(c)(2)).

The recordkeeping and recording burden for this collection of information is estimated at 0.3 hours per year. Send comments on EPA’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden to 608reports@epa.gov or by mail to: Section 608 Program Manager; Stratospheric Protection Division; Mail Code: 6205T; U.S. Environmental Protection Agency; 1200 Pennsylvania Avenue, NW; Washington, DC 20460. Include the OMB control number in any correspondence.

PART 1: ESTABLISHMENT INFORMATION

Name of Establishment	Street
(Area Code) Telephone Number	City State Zip Code

PART 2: SMALL CAN TEST DATA FORM

Enforcement Lot ID:		Full:		Upright:		T= 73 F:
		Half full:		Inverted:		T= 130 F:

Date:		Date:
Can ID	Initial time (hour)	Initial weight (g)	Final time (hour)	Final weight (g)	Delta days	Delta weight (g)	Adjusted annual rate (g/yr)

Number of Samples:		Average Loss Rate:
Technician:		Standard Deviation:

Comments:

SMALL CAN TEST DATA FORM

PART 3: BALANCE DATA LOG FORM

Rec #	Date	Time	Proj.	Prot.	Tech.	QC Code	Can		Recorded Grams	Comment
							Type	ID#
1
2
3
4
5
6
7
8
9
10
11
12
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14
15
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EPA FORM 5900-405