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**Form 1: [Fully Operational]{.underline}**[^1] **[Food Retail Stores
That Use HFC Refrigerants]{.underline}**

To qualify for GreenChill gold or silver-level store certification,
please answer the following questions about the store seeking
certification. There is guidance available on the certification program
to help you answer the questions at
http://epa.gov/ozone/partnerships/greenchill/certcenter.html.

Store Name:
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Street Address: \_\_\_\_\_

City: State: \_\_\_ Zip: \_\_\_\_\_

1\. Please list all refrigerants used in the store (including
self-contained commercial refrigeration equipment, remote commercial
refrigeration equipment, and HVAC equipment).
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2\. What is the store's total remote commercial refrigeration evaporator
heat load, including food merchandisers, food preparation rooms, and
food storage rooms (in 1000 BTUs/hour)? Do not include the store's HVAC
system (split systems or self contained). Do not include self-contained
commercial refrigeration equipment.
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3\. Please attach a copy of the store's refrigeration system legend
(schedule) that lists the BTUs of all remote commercial refrigeration
equipment.

4\. What is the store's total refrigerant charge for all remote
commercial refrigeration equipment (in lbs.)?

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5\. What is the annual refrigerant emissions rate of the entire store?
\[(amount of refrigerant emitted over the past 12 months ÷ the
refrigerant stock) x 100\] = % annual emissions rate. Include emissions
from self-contained commercial refrigeration equipment and remote
commercial refrigeration equipment. Do not include HVAC equipment.

Amount of refrigerant emitted over the past 12 months (in lbs.)
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Store's total refrigerant stock (in lbs.)
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Store's annual emissions rate (in %)
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6\. Please attach supporting documentation for annual emissions (in
lbs.) and refrigerant stock (in lbs.).

7\. Please have an authorized company representative certify with
his/her signature that all information contained in this application is
true and correct:

Signed and certified by:

Name: Title:

Signature: Date:

8\. Please give us contact information for a technical contact person
regarding the store certification:

Name: Title:

Street Address:

City: State: Zip:

Telephone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Email:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[^1]: Fully operational requires that a store can provide emissions data
    for several months (ideally 12 months).