Complete this form and place in client file.
1. Is the system the primary heat source? Yes____ No_____
2. What are the existing conditions of the system?
3. Describe recommended measure for existing situation:
4. What is your recommendation, based on cost and nature of the problem?
5. Who is making this recommendation?
Agency Representative Heating System Subcontractor
I certify that the above information is complete and accurate.
Signature of Agency Representative Date
Client Information: I have received information on safe operation, proper maintenance, and clean burning for my new (or repaired) solid fuel burning appliance system.
Client Signature Date
Link to Active Form: Exhibit 5.1.6A, Economic Analysis of Refrigerator Replacement
Variance #20 – SWS Section 7.8001.1a
Variance #20: DOE granted a variance from SWS Section 7.8001.1a Refrigerator & Freezer Replacement allowing: WA allows Energy Star rated or equivalent energy use Refrigerator replacements. DOE prohibits Freezer replacements.
Link to Active Form: