Ferguson Heating & Cooling Epa Authorization Form printable pdf download

FERGUSON HEATING & COOLING

EPA AUTHORIZATION FORM

To comply with the current Environmental Protection Agency’s (EPA) “Stratospheric Ozone Protection

Fact Sheet” dated April 27, 1995, the company below authorizes the EPA Certified individuals listed on

this form to place an order, to purchase, to sign for and to receive refrigerant or incomplete split systems

components which Ferguson Heating & Cooling supplies. These employees possess a Class 2 or

Universal Certification in accordance with EPA requirements under Section 608 Refrigerant Recycling

Rule. The company listed also understands that it is responsible to update this form should any change

occur. The EPA defines a complete split system to include a pre-charged outdoor section, pre-charged

line set and indoor coil. The EPA welcomes any questions you may have. The EPA hotline number is: 1-

800-296-1996.

COMPANY NAME:

____________________________________________________________________________________

MAILING ADDRESS:

____________________________________________________________________________________

CITY: _________________________________________STATE: ____________ ZIP CODE: _________

PHONE #: (______)______________________________________FAX #: (______)________________

EPA CERTIFIED INDIVIDUALS: (MUST ATTACH COPY OF EPA CARD AND DRIVER’S LICENSE)

NAME: _______________________________ TITLE: _________________________________

D.L. #: ________________________________ CFC REG: _____________________________

NAME: _______________________________ TITLE: _________________________________

D.L. #: ________________________________ CFC REG: ______________________________

NAME: _______________________________ TITLE: __________________________________

D.L. #: ________________________________ CFC REG: _____________________________

****USE ADDITIONAL SHEETS AS NEEDED****

THE FOLLOWING INDIVIDUALS ARE NOT EPA CERTIFIED, HOWEVER, ARE AUTHORIZED TO

ACCEPT DELIVERY OF ALL AND ANY REFRIGERANT OR INCOMPLETE SPLIT SYSTEM

COMPONENTS.

NAME: _________________________________TITLE: ____________________ D.L. #:_____________

NAME: _________________________________TITLE: ____________________ D.L. #: ____________

______________________________________ __________________________ _________________

AUTHORIZED SIGNATURE

TITLE

DATE

***ALL AREAS MUST BE FULLY COMPLETED***

***THIS FORM MUST BE SIGNED AND DATED TO BE VALID***

***A COPY OF EPA CARDS AND DRIVER’S LICENSE MUST ACCOMPANY THIS FORM***

Office Use Only:

Account Number: ___________________ Home Branch: ___________

Ferguson Heating & Cooling Epa Authorization Form