Name *

First Name

Last Name

Phone *

(###)

###

####

Facility Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (Leave Blank if Same as Facility Address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

LAYOUT DRAWING OF FACILITY SHOWING LOCATION OF EXTRACTION ROOM AND STORAGE LOCATIONS FOR HAZARDOUS MATERIALS *

YES

NO

MECHANICAL DRAWING SHOWING LOCATIONS OF HVAC UNITS AND DUCT ROUTING *

YES

NO

MANUFACTURER SPEC SHEETS FOR ALL EXHAUST FANS, MAKEUP AIR UNITS, FIRE DAMPERS, ETC *

YES

NO

MANUFACTURER NAME AND PRODUCT NUMBERS FOR GAS DETECTION COMPONENTS AND/OR CO 2 SENSORS (INCLUDING SPEC SHEETS IF AVAILABLE) *

YES

NO

MANUFACTURER SPEC SHEETS FOR BACKUP POWER EQUIPMENT USED TO SUPPORT EMERGENCY/SAFETY SYSTEMS *

YES

NO

MANUFACTURER SPEC SHEETS FOR EACH ELECTRICAL COMPONENT USED IN EXTRACTION ROOM (IF BUTANE OR PROPANE ARE PRESENT) *

YES

NO

CERTIFICATION DOCUMENTS FOR EACH EXTRACTION SYSTEM USED IN THE EXTRACTION ROOM *

YES

NO