Appendix A to Subpart S of Part 431 - Compliance Statement for Metal Halide Lamp Ballasts

Equipment: Metal Halide Lamp Ballasts Manufacturer's or Private Labeler's Name and Address: [Company name] (“the company”) submits this Compliance Statement under 10 CFR Part 431 (Energy Efficiency Program for Certain Commercial and Industrial Equipment) and Part A of the Energy Policy and Conservation Act (Pub. L. 94-163), and amendments thereto. I am signing this on behalf of and as a responsible official of the company. All basic models of metal halide lamp ballasts subject to energy conservation standards specified in 10 CFR Part 431 that this company manufactures comply with the applicable energy conservation standard(s). We have complied with the applicable testing requirements (prescribed in 10 CFR Part 431) in making this determination, and in determining the energy efficiency set forth in all Certification Reports submitted by or on behalf of this company. All information in such Certification Report(s) and in this Compliance Statement is true, accurate, and complete. The company pledges that all this information in any future Compliance Statement(s) and Certification Report(s) will meet these standards, and that the company will comply with the energy conservation requirements in 10 CFR Part 431 with regard to any new basic model it distributes in the future. 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. Name of Company Official: Signature of Company Official: Title: Firm or Organization: Date: Name of Person to Contact for Further Information: Address: Telephone Number: Facsimile Number: Email: Third-Party Representation (if applicable) For certification reports prepared and submitted by a third-party organization under the provisions of 10 CFR Part 431, the company official who authorized said third-party representation is: Name: Title: Address: Telephone Number: Facsimile Number: Email: The third-party organization authorized to act as representative: Third-Party Organization: Address: Telephone Number: Facsimile Number: Email: Submit by Certified Mail to: U.S. Department of Energy, Building Technologies Program, Mailstop EE-2J, 1000 Independence Avenue, SW, Washington, DC 20585-0121. Submit by e-mail in PDF format (which shows original signature) to the U.S. Department of Energy, Buildings Technologies Program at: [e-mail].