Name *

First Name

Last Name

Phone

(###)

###

####

Facility Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (Leave Blank if the 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 Co2 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

Requested Certification Completion Date

MM

DD

YYYY