17652 Water Heater Work Completion Form

energy right® Program Water Heater Plan Work Completion Form

OMB No. 3316-0019 Expires: 3/31/2007

1.

Power Distributor:

     

2.

Work ID Number:

     

(Work ID Number is assigned by energy right Information System)

3.

Inspection Open Date:

     

(mm/dd/yyyy)

4.

Legal 911 Address of Property:

     

     

Street Address

City, State, Zip Code

5.

Structure:

Single Family

Multi-Family

Business

6.

Number of Dwellings/Businesses at this Address:

     

7.

Type System Replaced:

Electric Resistance

Fossil-Fuel

New Load

Other

     

8.

Enter Number of Water Heaters Invoiced For:

Standard Water Heaters

     

Advanced Water Heaters

     

Water Heaters for DLC Switch

     

9.

Total Storage Capacity:

     

(gallons)

For Distributor Records (Complete the following where required by distributor):

1.

Date Passed TVA Requirements:

     

(mm/dd/yyyy)

2.

Subdivision or Customer Name:

     

3.

Account (or Meter) Number:

     

4.

Total Heating Capacity:

     

(kW)

5.

Water Heater Brand 1:

     

Water Heater Brand 2:

     

6.

Retailer Name:

     

7.

Lifetime Warranty:

Yes

No

8.

Average Energy Factor Rating:

     

9.

Installed by:

     

10.

Inspector:

     

11.

Date Passed Local Standards:

     

12.

Incentive Paid:

$

     

Retained MVP:

$

     

13.

Natural Gas Available?

Yes

No

14.

Contractor Paid?

Yes

No

15.

Comments:

     

TVA 17652 [11-2004]