5900-194 Modular Plant Qualification Form

ENERGY STAR^® Qualified Homes, Version 2.5

_{Modular Plant Qualification Form}

OMB Control No. 2060-0586

I, (Name of Certifier) hereby certify that

_{(Manufacturer Name) , located at}

(Address, City, State) has demonstrated the ability consistently to produce ENERGY STAR qualified modular homes and is therefore

authorized to apply the SBRA ENERGY STAR quality assurance label to new modular homes manufactured under the terms and conditions of the ENERGY STAR New Homes program.

_{Signature: Date:}

_Company:

_{Plant Contact: Title:}

_{Phone: Fax:}

_E-Mail:

ENERGY STAR design method

(Must check one below)

 Prescriptive Path (ENERGY STAR Reference Design)

 Computer analysis to comply under the Performance Path (attached)

ENERGY STAR features incorporated into factory quality assurance procedures

(Must check all applicable boxes below)

 Information included in third-party-approved design package

 Information included in plant Quality Control Manual

 Information included in builder installation instructions

ENERGY STAR modular home checklists

(Must check below)

 Inspection Checklists developed identifying items that must be verified in plant and at the building site

Homes inspected and tested in the field

(Must check below)

 Three (3) homes meet ENERGY STAR requirements

ENERGY STAR included into routine factory operations

(Must check all boxes below)

 Corrective actions identified during tests implemented and documented

 Key plant personnel trained on critical processes and procedures

 Unique features in ENERGY STAR third-party-approved packages reviewed with plant’s third-party design approval agencies

 Process in place for collecting, tracking and archiving documentation on ENERGY STAR

Submit this form to SBRA:

Fax number: 212-496-5389, or

Mailing address: 1776 Broadway, Suite 2205, New York, NY 10019, or

_{Email: info@research-alliance.org}

EPA Form 5900-194

The government estimates the average time needed to fill out this form is 0.2 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.

www.research-alliance.org Rev. 9/2011