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

Please Select All Solvents That Will Be Used

100% Butane

70/30 Butane-Propane Mix

100% Propane

Ethanol

Supercritical CO2

Other

Will There Be Multiple Control Areas?

YES

NO

Is All Electrical Equipment Inside the Extraction Area C1D1/C1D2 Rated?

YES

NO

Is Your Unit Anchored to Prevent Seismic Tipping for Your Location?

YES

NO

Is Your Unit Grounded to Prevent Static Electricity Build-Up?

YES

NO

Does Your Extraction Room Have Power?

YES

NO

Does Your Extraction Room Have Lights?

YES

NO

Does Your Extraction Room Have a Backup Power System?

YES

NO

Does Your Extraction Room Have Ventilation?

YES

NO

Does Your Extraction Room Have Gas Detection?

YES

NO

Is Your Ancillary Equipment Plumbed Through the Wall from The Outside?

YES

NO

Will a Pre-built Extraction Booth be used?

YES

NO

Requested Certification Completion Date

MM

DD

YYYY