EPA Certification Proof Of

EPA Certification Proof of 608 and/or 609 Certifications **********INSTRUCTIONS: Return this form via mail or fax together with a copy of ONE current employees certification card*********************************

I hereby notify USA Refrigerants that our company or legal entity listed below is eligible by law to purchase Class I, Class II and other regulated refrigerants after November 14th, 1994 because: (Check applicable paragraphs in section A or B)

(Section A)

{ } Contractor Resale - The above specified refrigerants purchased by us (the contractor) after November 13th, 1994 are being purchased exclusively for eventual resale. Contractor will collect all applicable taxes from their customer.

{ } (Technician Certification) - We employ at least one technician who has been certified in accordance with EPA for 608 Certification and/or 609 Certification under regulation 40 CFR 82 subpart F. (HVAC-equipment) or 40 CFR 82 subpart B (motor vehicles). We have enclosed a copy of at least one current employees certification identification card.

Name of Certified Technician: ______

(Section B)

{ } Wholesaler Resale - The above specified refrigerants purchased by us after November 13th, 1994 are being purchased exclusively for eventual resale to certified technicians or to other refrigerant resellers (no certification card necessary). In the event that any of the above certified information changes we will provide notification of the change(s) prior to additional purchases of these refrigerants.

Signature:______Date:______

FORM COMPLETED BY:

NAME: ______

TITLE: ______

COMPANY NAME: ______

ADDRESS: ______

CITY: STATE: ______ZIP: ______

TELEPHONE #: ______FAX #: ______

E-MAIL: ______

You will be enrolled in our Registry of certified technicians and/or companies that are entitled to purchase refrigerants.

MAIL to: USA Refrigerants 155 Airport Executive Park, Nanuet, New York 10954 Fax to: 845-425-5338 Phone: 1-800-898-4872