Appendix C to Subpart B of Part 431—Compliance Certification

Appendix C - Appendix C to Subpart B of Part 431—Compliance Certification

Certification of Compliance With Energy Efficiency Standards for Electric Motors (Office of Management and Budget Control Number: 1910-1400. Expires February 13, 2014)

An electronic form is available at https://www.regulations.doe.gov/ccms/.

1. Name and Address of Company (the “company”):

2. Name(s) to be Marked on Electric Motors to Which this Compliance Certification Applies:

3. If manufacturer or private labeler wishes to receive a unique Compliance Certification number for use with any particular brand name, trademark, or other label name, fill out the following two items:

A. List each brand name, trademark, or other label name for which the company requests a Compliance Certification number:

B. List other name(s), if any, under which the company sells electric motors (if not listed in item 2 above):

Submit electronically at https://www.regulations.doe.gov/ccms.

Submit paper form by Certified Mail to: U.S. Department of Energy, Office of Energy Efficiency and Renewable Energy, Building Technologies (EE-2J), Forrestal Building, 1000 Independence Avenue, SW., Washington, DC 20585-0121.

This Compliance Certification reports on and certifies compliance with requirements contained in 10 CFR Part 431 (Energy Conservation Program for Certain Commercial and Industrial Equipment) and Part C of the Energy Policy and Conservation Act (Pub. L. 94-163), and amendments thereto. It is signed by a responsible official of the above named company. Attached and incorporated as part of this Compliance Certification is a Listing of Electric Motor Efficiencies. For each rating of electric motor* for which the Listing specifies the nominal full load efficiency of a basic model, the company distributes no less efficient basic model with that rating and all basic models with that rating comply with the applicable energy efficiency standard.

* For this purpose, the term “rating” means one of the combinations of an electric motor's horsepower (or standard kilowatt equivalent), number of poles, motor type, and open or enclosed construction, with respect to which § 431.25 of 10 CFR Part 431 prescribes nominal full load efficiency standards.

Person to Contact for Further Information:

Name: Address: Telephone Number: Facsimile Number:

If any part of this Compliance Certification, including the Attachment, was prepared by a third party organization under the provisions of 10 CFR 431.36, the company official authorizing third party representations:

Name: Address: Telephone Number: Facsimile Number:

Third Party Organization Officially Acting as Representative:

Third Party Organization: Responsible Person at the Organization: Address: Telephone Number: Facsimile Number:

All required determinations on which this Compliance Certification is based were made in conformance with the applicable requirements in 10 CFR Part 431, subpart B. All information reported in this Compliance Certification is true, accurate, and complete. The company is aware of the penalties associated with violations of the Act and the regulations thereunder, and is also aware of the provisions contained in 18 U.S.C. 1001, which prohibits knowingly making false statements to the Federal Government.

Signature: Date: Name: Title: Firm or Organization: Attachment of Certification of Compliance With Energy Efficiency Standards for Electric Motor Efficiencies Date: Name of Company:

Motor Type (i.e., general purpose electric motor (subtype I), fire pump electric motor, general purpose electric motor (subtype II), NEMA Design B general purpose electric motor)

Motor horsepower/standard kilowatt equivalent	Least efficient basic model—(model numbers(s)) Nominal full-load efficiency								Open motors (number of poles)				Enclosed motors (number of poles)				8	6	4	2	8	6	4	2	1/.75	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	1.5/1.1	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	2/1.5	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	3/2.2	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	5/3.7	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	Etc	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______

Note: Place an asterisk beside each reported nominal full load efficiency that is determined by actual testing rather than by application of an alternative efficiency determination method. Also list below additional basic models that were subjected to actual testing.

Basic Model means all units of a given type of electric motor (or class thereof) manufactured by a single manufacturer, and which (i) have the same rating, (ii) have electrical design characteristics that are essentially identical, and (iii) do not have any differing physical or functional characteristics that affect energy consumption or efficiency.

Rating means one of the combinations of an electric motor's horsepower (or standard kilowatt equivalent), number of poles, motor type, and open or enclosed construction, with respect to which § 431.25 of 10 CFR Part 431 prescribes nominal full load efficiency standards.

Models Actually Tested and Not Previously Identified

Motor horsepower/standard kilowatt equivalent	Least efficient basic model—(model numbers(s)) Nominal full-load efficiency								Open motors (number of poles)				Enclosed motors (number of poles)				8	6	4	2	8	6	4	2	______	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______	Etc	______	______	______	______	______	______	______	______		______	______	______	______	______	______	______	______

[69 FR 61923, Oct. 21, 2004, as amended at 76 FR 59006, Sept. 23, 2011]