5900-587 GreenChill Advanced Refrigeration Partnership Fully Oper

~Confidential Business Information~¹

Fully Operational² Food Retail Stores

To qualify for GreenChill platinum-, gold-, or silver-level store certification, please answer the following questions about the store seeking certification.

STORE NAME (as you would like it to appear on the award certificate):

     

STORE #:

     

STREET ADDRESS:

     

CITY:

     

State:

     

Zip:

     

Refrigeration System Type and Manufacturer (check one box for the medium temperature system and list the manufacture of that system, and check one box for the low temperature system and list the manufacturer of that system)

System Type

Medium Temperature Sytem

Low Temperature System

Type

Manufacturer

Type

Manufacturer

Centralized Direct Expansion Parallel Rack

     

     

Distributed Direct Expansion

     

     

Glycol Secondary Loop

     

     

CO2 Secondary Loop

     

     

CO2 Cascade

     

     

CO2 Transcritical

     

     

Other (please specify):      

     

     

Refrigerant TYpe and Charge Size (complete the table below)

EQUIPMENT TYPE	Remote Commercial Refrigeration System		Self-Contained Equipment*	HVAC Equipment**
	Medium Temperature	Low Temperature
Primary Refrigerant Type	     	     	     	     
Primary Refrigerant Charge (lbs)	     	     
Secondary Refrigerant Type	     	     
Secondary Refrigerant Charge (lbs)	     	     
*Including soda machines, vendor supplied coolers, ice machines, refrigerators in deli areas, etc.
**Including “personal” AC in staff offices

Total remote commercial refrigeration load (MBTUs/hour):

     

DO NOT include the store’s HVAC system (split systems or self contained), self-contained refrigeration equipment, sub-cooling, heat of rejection, or pump heat.

Amount of Refrigerant (LBS) emitted over the last 12 months:

     

DO NOT include emissions from HVAC equipment or self-contained refrigeration equipment.

6. Required Attachments Checklist

A. Store’s RefrigeraTion System Legend (schedule): A copy of the store’s current refrigeration system legend (schedule) that lists the BTU output of all remote commercial refrigeration equipment.

B. Supporting Documentation for Refrigerant Charge: A letter, signed by an authorized installation company representative, detailing the amount of refrigerant (lbs.) the commercial refrigeration system holds when properly charged. Due to possible leaks, invoices are not sufficient for verifying a system’s charge.

C. Supporting Documentation for Annual Emissions or Emissions Rate: Documentation may include an emissions report from a store’s leak tracking software.

7. Signature/Certification by Authorized Company Representative

Please have an authorized representative of the store seeking certification sign this application to attest that all information contained is true and correct.

Name:	     			Title:	     
Telephone:			     	Email:	     
Signature:		     		Date:	     

8. Contact Information

Please provide contact information for a technical contact regarding the store certification application.

Name:	     			Title:	     
Street Address:			     
City:	     			State:		     	Zip:	     
Telephone:		     		Email:		     

For assistance on completing the form, please refer to the GreenChill Store Certification Program Guidance. Please direct any questions and send completed forms and attachments to Kersey Manliclic (Manliclic.Kersey@epa.gov, 202-566-9981).³

GreenChill reserves the right to deny store certification based on a company's Clean Air Act Title 6 enforcement issues

Note: When referring to any EPA Award, please include the year in which the award was received.

OMB Control No.: 2060-0702 Expiration Date: MM/DD/YYYY

EPA Form No.: 5900-587

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0702). Responses to this collection of information are voluntary (Clean Air Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 7 hours per response. 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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.

1 All information provided will be treated as confidential business information (CBI), as stipulated under Clean Air Act provisions, and will not be divulged either to other partners or publicly.

2 Fully operational requires that a store can provide actual emissions data for ideally 12 months.

3 If you do not receive an email confirming receipt of your application within 2 business days, please notify EPA.