Transcription of REFRIGERANT REMOVAL VERIFICATION STATEMENT
1 DLA DISPOSITION SERVICES FORM 2016, JUN 2011 REFRIGERANT REMOVAL VERIFICATION STATEMENT (Prescribing Authority: 40 CFR (f)(2) & DoD )THE REFRIGERANT HAS BEEN REMOVED FROM THE ITEM(S) LISTED BELOW, IN COMPLIANCE WITH THE CLEAN AIR ACT AMENDMENTS OF 1990, SECTION 608, AND EPA REGULATIONS AT 40 CFR Who Removed RefrigerantStreet AddressCityStateZip CodeDate RemovedItem Description*Item QtyDTID # (Enter one only)Total Item QtyPrinted 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.
2 As long as the DTID number is permanently marked on each item, a single form similar to the one above will suffice.
