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Intent to Verify

Manufacturers of retrofit technologies or other parties interested in participating in the Diesel Retrofit Technology Verification Program may notify us of their intent to verify by completing this Technology Information and Intent to Verify Form ; or downloading the MS Word version (1 pp, 29K, MS Word reader for document files Exit EPA Disclaimer) of this form formatted for print.

1. Company name ______________________________

2. Contact information:

3. Type of product to be verified ______________________________
(if a system is required, submit information on all components)

4. Name of product to be verified ______________________________

5. Is product described in item 4 above commercially available?   ___yes   ____no

6. Application ______________________________
e.g., mobile heavy-duty diesel highway and marine engines)

7. Applicable engines ______________________________

8. Emission reduction range for pollutants :
   NOx ___________
   PM ___________
   HC ___________
   CO ___________
   CO2 ___________

9. Description of operation ______________________________

10. Identify any information provided that is considered business confidential ______________________________

11. Do you intend to officially submit an application for verification for this product?   ___yes   ____no

12. If you answered yes to item 11, on what date do you anticipate officially submitting a completed application? _________________________

Send this form via e-mail to :   CleanDiesel@epa.gov

or by regular mail to:

Diesel Retrofit Team
US Environmental Protection Agency
OAR/OTAQ/CISD/ISG
Mail Code 6405J
1200 Pennsylvania Avenue, NW
Washington, DC  20460

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