5900-589 GreenChill Advanced Refrigeration Partnership Installati

Installation Leak Tightness Testing: Verification Form

The following form must be completed by an authorized installation company representative to verify that your store’s remote commercial refrigeration system was tested for leaks at the time of installation in accordance with GreenChill’s Best Practices Guideline for Leak Tightness at Installation. Please refer to the Guideline for more details.

Store Contact Information

Store Name:		     					Location:		     
Installation Company Name:				     
Representative’s Name:			     					Title:	     
Telephone:	     				Email:	     

Leak Testing Information

• Pressure Testing for Leaks:

Tracer gas used:      

The system pressure was brought up to       psig and was successfully held for       hours.

• Stairstep Evacuation Procedure:

First vacuum was pulled down to       microns and was successfully held for       hours.

Second vacuum was pulled down to       microns and was successfully held for       hours.

Third vacuum was pulled down to       microns and was successfully held for       hours.

Signature/Certification by Authorized Company Representative

By signing this form I attest that all information contained is true and correct.

Signature:

     

Date:

     

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

EPA Form No.: 5900-589

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. Please direct any questions and send completed forms and attachments to Kersey Manliclic (Manliclic.Kersey@epa.gov, 202-566-9981).