5900-187 HPw/ES Test Out Form

Home Performance with ENERGY STAR

OMB Control No. xxxx-xxxx

Post-Installation Tests and Inspections

[Enter Company Name]

Customer Name:

Customer Phone Number (h):

Customer Address:

Customer Phone Number (w):

City, State, Zip:

Customer Email:

Inspection Date:

Home Performance Analyst:

Blower Door Test and Ventilation Compliance

Method Used to Determine Building Leakage Standard (check one):

Bldg Leakage (Test-In):

CFM50 / ACH

Bldg Leakage (Test-Out):

CFM50 / ACH

□

Whole Building Mechanical Ventilation per ASHRAE 62.2 - 2007

(circle one)

(circle one)

□

Ventilation Credit for Air Leakage (indicate software used):

CFM50 / ACH / Mech. Ventilation CFM

□

TECTITE

□

ZipTest Pro2

(circle one)

□

Ventilation Exemption for Existing Homes per ASHRAE 62.2 - 2007

□

Pass

□

Pass w/ Ventilation Recommended

□

BPI Legacy Building Air Tightness Std per ASHRAE 62.2 - 1989

□

Fail - Action Required:

□

Other:

Combustion Equipment Testing / Combustion Appliance Zone Testing

Worst Case Test Results

Natural Condition Test Results

Spillage

Draft

CO

Spillage

Draft

CO

Flue Inspection

Heating System 1:

Pass Fail

pa

ppm

Pass Fail

pa

ppm

Pass Fail

□

Action Required:

Heating System 2:

Pass Fail

pa

ppm

Pass Fail

pa

ppm

Pass Fail

□

Action Required:

DHW System 1:

Pass Fail

pa

ppm

Pass Fail

pa

ppm

Pass Fail

□

Action Required:

Other:

Pass Fail

pa

ppm

Pass Fail

pa

ppm

Pass Fail

□

Action Required:

CO Ambient

Base Pressure

Worst Case Pressure

Net CAZ Depress.

Limit for CAZ

Result

CAZ 1:

Pass Fail

□

Action Required:

CAZ 2:

Pass Fail

□

Action Required:

Gas Leak Testing:

□

No Leaks Detected

□

Leaks Detected as Noted:

Kitchen

Main Living

Other - ppm

Ambient CO:

□

Action Required:

Fuel

CO ppm

Vent Out?

Oven CO:

Yes No

□

Action Required:

Dryer Vent:

□

Electric

□

Gas Properly Vented

□

Gas Improperly Vented. Action Required:

Distribution System Air Flow (required if ducts were sealed as part of project) and Leakage Test

Airflow Test Result:

□

Pass

□

Fail

Duct Leakage Test:

Duct Blaster

BD Subtract

Delta Q

Press Pan

If fail, action to be taken:

Duct Test Result (enter here or attach separate form):

Pressure Pan Average (Test-In):

Pressure Pan Average (Test-Out):

Verification of Measures Installed:

□

Attic Stairs Insulation

□

DHW System Replace / Repair

□

Health & Safety:

□

Basement Air Sealing

□

Attic Tent

□

DHW Blanket / Pipe Insulation

□

Attic Air Sealing

□

Window Replacement / Repair

Qty:

□

Exhaust Fans - Qty _____ / HRV

□

Other:

□

Basebrd / Molding Air Sealing

□

Window Film / Solar Screen

Qty:

□

Exhaust Vents Reroute / Insulate

□

Windows / Doors Air Sealing

□

Door Replace / Repair

Qty:

□

Attic Vents

Qty:

□

Other:

□

Ext. Wall to Garage Air Sealing

□

Heating System Replace / Repair

□

Appliance:

□

Attic Flat Insulation

□

Central Air Conditioner Replace / Repair

□

Appliance:

□

Notes/Items Requiring Follow-Up:

□

Attic Slope Insulation

□

Htg / DHW Flue Replace / Repair

□

Appliance:

□

Attic Kneewall Insulation

□

Air Handler Replace / Repair

□

Lighting:CFL's / Fixt.

Qty:

□

Exterior Wall Insulation

□

Duct Sealing / Insulation / Replacement

□

Renewable Energy Syst: ___________

Contractor Statement and Signature:

I attest that all of the information entered above is correct to the best of my knowledge. I agree to complete any items noted above for follow-up corrective action, and will submit an additional Post-Installation Tests and Inspections form that verifies the successful completion of those items and records required follow-up tests or inpsections:

Contractor Signature:

Date:

Customer Statement

I attest that I am the owner of the property specified above, and that all materials and equipment included my home improvement contract with the above Contractor have been furnished and installed by the Contractor, and that the work has been completed pursuant to the contract.

Customer Signature:

Date:

EPA Form 5900-187

The government estimates the average time needed to fill out this form is 1.00 hours and welcomes suggestions for reducing this effort.

Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.