Form 5900-586 GreenChill Advanced Refrigeration Partnership Newly Cons

~Confidential Business Information~¹

Newly Constructed² Food Retail Stores

To qualify for GreenChill platinum-, gold-, or silver-level store certification, please answer the following questions about the store seeking certification.

STORE NAME (as you would like it to appear on the award certificate):

     

STORE #:

     

DATE OF STORE OPENING:

     

STREET ADDRESS:

     

CITY:

     

State:

     

Zip:

     

Refrigeration System Type and Manufacturer (check one box for the medium temperature system and list the manufacture of that system, and check one box for the low temperature system and list the manufacturer of that system)

System Type

Medium Temperature Sytem

Low Temperature System

Type

Manufacturer

Type

Manufacturer

Centralized Direct Expansion Parallel Rack

     

     

Distributed Direct Expansion

     

     

Glycol Secondary Loop

     

     

CO2 Secondary Loop

     

     

CO2 Cascade

     

     

CO2 Transcritical

     

     

Other (please specify):      

     

     

Refrigerant TYpe and Charge Size (complete the table below)

EQUIPMENT TYPE	Remote Commercial Refrigeration System		Self-Contained Equipment*	HVAC Equipment**
	Medium Temperature	Low Temperature
Primary Refrigerant Type	     	     	     	     
Primary Refrigerant Charge (lbs)	     	     
Secondary Refrigerant Type	     	     
Secondary Refrigerant Charge (lbs)	     	     
*Including soda machines, vendor supplied coolers, ice machines, refrigerators in deli areas, etc.
**Including “personal” AC in staff offices

pREDICTED HFC Refrigerant Annual Emissions (LBS):

     

Annual emissions should be predicted for the HFC refrigerant in the remote commercial refrigeration equipment once the store is fully operational. If an HFC refrigerant is not used, this question may be left blank.

Total remote commercial refrigeration load (MBTUs/hour):

     

DO NOT include the load from the store’s HVAC system (split systems or self-contained), self-contained refrigeration equipment, sub-cooling, heat of rejection, or pump heat.

6. Required Attachments Checklist (If an HFC refrigerant is not used, Attachments C, D, and E are not required)

A. Store’s RefrigeraTION System Legend (schedule): A copy of the store’s refrigeration system legend (schedule) that lists the BTU output of all remote commercial refrigeration equipment.

b. Supporting Documentation for Refrigerant Charge: A letter, signed by an authorized installation company representative, detailing the amount of refrigerant (lbs.) the commercial refrigeration system holds when properly charged. Due to possible leaks, invoices are not sufficient for verifying a system’s charge.

C. Letter Stating Equipment Manufacturer’s Predicted HFC Annual Emissions or Emissions Rate: A letter, signed by an authorized representative of each commercial refrigeration system manufacturer predicting this store’s annual emissions (lbs.) or emissions rate (%) and the rationale for that prediction.

d. Supporting Documentation for Predicted HFC Annual Emissions or Emissions Rate: Documentation supporting the predicted annual emissions (lbs.) or emissions rate (%). Documentation may include any or all of the following, or any other supporting evidence deemed helpful: a list of emissions or emissions rates from other stores using the same technology as the store seeking certification; a list of emissions or emissions rates from other stores serviced by the same service technicians installing equipment in the store seeking certification; a list of special features of the store seeking certification that lead to reduced emissions and emissions rates, etc.

E. installation leak tightness testing verification form: Please have an authorized installation company representative complete and sign the Installation Leak Tightness Testing: Verification Form to verify that he/she tested the remote commercial refrigeration system per GreenChill’s Best Practices Guideline for Leak Tightness at Installation prior to the store’s opening.

7. Signature/Certification by Authorized Company Representative

Please have an authorized representative of the store seeking certification sign this application to attest that all information contained is true and correct.

Name:	     			Title:	     
Telephone:			     	Email:	     
Signature:		     		Date:	     

8. Contact Information

Please provide contact information for a technical contact regarding the store certification application.

Name:		     			Title:		     
Street Address:				     
City:	     					State:			     	Zip:	     
Telephone:			     		Email:			     

For assistance on completing the form, please refer to the GreenChill Store Certification Program Guidance. Please direct any questions and send completed forms and attachments to Kersey Manliclic ([email protected], 202-566-9981).³

GreenChill reserves the right to deny store certification based on a company's Clean Air Act Title 6 enforcement issues

Note: When referring to any EPA Award, please include the year in which the award was received.

OMB Control No.: 2060-0702 Expiration Date: MM/DD/YYYY

EPA Form No.: 5900-586

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0702). Responses to this collection of information are voluntary (Clean Air Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 7 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

1 All information provided will be treated as confidential business information (CBI), as stipulated under Clean Air Act provisions, and will not be divulged either to other partners or publicly.

2 A newly constructed store is one that is applying for GreenChill certification before it opens to the public, so it does not have any actual refrigerant emissions data at the time of the certification application. Stores that have only been operational for a few months may also fit into this category.

3 If you do not receive an email confirming receipt of your application within 2 business days, please notify EPA.