Qualified Product Information For by pengtt

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									OMB Control No. 2060-0528 Approval Expires 03/31/2011

United States

ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460 Qualified Product Information Form for Roof Products Version 2.0 Office of Atmospheric Programs
ENERGY STAR® Qualified Product Information (QPI) Form for use by ENERGY STAR Roof Products Partners (Companies who have joined ENERGY STAR for Roof Products by signing the Partnership Agreement). Information from this form will be added to the list of ENERGY STAR Qualified Roof Products on the ENERGY STAR Web site at www.energystar.gov.
Note: Partners may use this QPI form to report only those products that are sold under the company’s brand name. If your firm sells its products to another company that uses its own brand name, that company must join ENERGY STAR and report its own products. Please complete this form and send it back via fax, e-mail, or mail to the address given below.

I. Contact Information
Company Name: (as listed in the PA) Name of Person Submitting Information:

Tel: E-mail:

Fax:

II. Roof Product Information
Solar Reflectance After 3 years Initial Thermal Emittance* Warranty (years) Roof cleaned prior to 3rd year test?

Brand

Model

Initial Solar Reflectance

III. Testing Information (Test results must be included with this form)
Testing Information Tested By (Name of Firm or Self-Tested): Initial Solar Reflectance Solar Reflectance After 3 Years** Initial Thermal Emittance*

Test Method Used
*Note: Roof products are not required to meet minimum thermal emittance levels to earn the ENERGY STAR. However, EPA is requiring manufacturers to report initial thermal emittance values for ENERGY STAR qualification. This information will be included on the ENERGY STAR website. **Note: As of December 31, 2007, samples being used to test for solar reflectance after 3 years may not be cleaned prior to t esting.

Is this product a Color Family Representative Element?*** Is this product a Color Family Additional Element?***

Y

N Y

N

ENERGY STAR, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA Toll-free number 1-888-STAR-YES; Web site http://www.energystar.gov
ENERGY STAR is a registered US mark.

EPA Form No. 5900-75

OMB Control No. 2060-0528 Approval Expires 03/31/2011

***Note: If this product is being submitted as part of a Color Family, the CRRC-F-2 form must be included with this form.

ENERGY STAR, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA Toll-free number 1-888-STAR-YES; Web site http://www.energystar.gov
ENERGY STAR is a registered US mark.

EPA Form No. 5900-75

OMB Control No. 2060-0528 Approval Expires 03/31/2011

IV. Roof Product Description (complete the appropriate boxes below):
Type of Roof Product (Please specify in detail): Application Markets Y N Low Slope: Steep Slope:

Types of Applications (Please describe in detail the major uses and applications this product was designed for):

V. Product Labeling Requirements
Is Energy Star label clearly displayed: In product literature? On Internet site?

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

VI. Declaration and Signature
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 19 U.S.C. section 1001. Signature: Printed Name: Date:

VII. Contact Information:
Please submit your completed QPI Form to ENERGY STAR for Roofs Email: roofs@energystar.gov Fax: (202) 862-1144 US Mail/Overnight Express: 1725 Eye St., NW, Suite 1000, Washington, DC 20006

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 hours per respo nse. 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, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA Toll-free number 1-888-STAR-YES; Web site http://www.energystar.gov
ENERGY STAR is a registered US mark.

EPA Form No. 5900-75


								
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