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Audit Work Completed

Customer Name Address Technician Date Name





Maio Telephone Account Holder Name: Zip Code At no cost to you. UPA will../ I II Referral Recommended (RecommendedI not applicable) DANE WARREN REAP Field Technician Name REAP Field Technician Signature /---- //-/0 Date -f vor... 17 dver • NY State !__ lIPA Account j NB N!! (ifdlffe-rent jram the ResldentiaJ Oient) ~tf'V or~ I Ave.e~/& .. to help reduce products/services to improve your health./ .002_ Our Participation Agreement. to lower you energy Secure all assistance dollars available and arrange for Follow the personal and family action plan for electric savings not C n/a Action Plan for Electrical Saving Filter replaced/cleaned tV L /I(AI.greement Address: 60 City Jttin:1 tc _J_ 11 1V1775 (/Crn rqr Ii q t. every month bill for kilowatt hour usage in order to track efforts success of efficiency assignment to L1PA in discovering ways. o Provide an energy evaluation.- ph P'j-e eFt- & Safety .Energy Affordability Partnership Program Project No...doc Page 1j1 . .. or o Perform a Comprehensive Home Assessment Provide Education needs INSTALL customized INSTALL customized energy saving your energy usage (and costl] safety and comfort Energy Saving Measure Air Conditioner Air Leakage sealing Compact Florescent Duct Insulation Duct Leakage Repairs/Testing Health bulbs installed (CompletedI applicable) sessions to help understand your energy You agree to . Customer N me Dale REAP _03./ Testing Low-flow Low-flow Faucet Aerators Showerheads Adjustment Water Pipe insulation Water Heater Temperature Proposed Attic Work (ProposedI not applicable] Insulation A n/a I Wall I Basement I Repair Repair Electrical Work HVAC Tune Up Plumbing Refrigerator Weatheriz. V ..Residential . Customer Name: Our Participation A. Actively participate cost Allow REAP reps to return Check your monthly to the home for follow-up visit Pay you electric bill on time./ Col? rh.ation Other Custom Work: .

....ame: (if dJffer:f!ntfrom the Residentiat Cli~nt) M>~&Y} r..... .:usehold Member. _ _ __ . .._.... and the annual income of each. . .... provided in this document is intended to of my entire household's below certifies that the list of occupants representation is an accurate and complete I understand that REAP program meeting certain income qualifications and that my household must meet those qualifications for program my household participation.. .. Cust L/ (/'::.._.-6 Zip Code Account w Holder Signature Please list all persons living in the home. -- Annual Income .._...or its designee._ dJ. TOTAL Annual Household Income: i .. to evaluate my energy use patterns or services offered through contained in order to identify Energy purposes and and actual energy savings resulting from work performed Partnership.. Review Certification indicated total gross household below indicates that I have reviewed above and certify thatthe DANE WARREN REAP Field Technician Name P Field Technician Signature Date REAP_02 ...'"1/' rName (/ the customer's household income verification documentation income is as indicated above and is within the .. _ D7::L __ __ _ ..-. that information the Residential in this form shalt be used solely for program shall not be released to any outside parties. /. 01_ Eligibility Verification 0 and Certification..._.__ .'l ... 1 __ __ ...Residential Energy Affordability Partnership Program Project No.. --- j Source ----! _ ~~~~~~~~~~~~--~-~-i- 35 of Income VCD c----~~~~~----------+ . i ..a Citv )-1QyF/ow-e?-. :--------------~ II Customer's My signature assist families Certifying Signature of AGREEMENT (my household) and their income information income._. except as required by law."_._ ... Customer Name: Address: PROGRAM ELIGIBILITY VERIFICATION & CERTIFICATION 1 LlPA Account N~ Main Telephone NQ tf... .. enter Name 0"7 _____...._...doc . .... income.IfveI Account Holder N.... l_ .. -... If any individual listed does no earn an income. I also understand that I am expected to provide proof of income to REAP representatives regarding I hereby authorize potential AffordabiHty the release of information I understand to L1PA. If} ..REAPProgram Income Dale Field Technician's My signature Guidelines. ~li-NY State /)0.-. zero (0) in the income column.

HEALTH AND SAFETY CONDITIONS ACKNOWLEDGEMENT Home Telephone Daytime Telephone NQ NQ Other. which could cause illness or death elevated CO levels could cause illness or death may develop ~_ may develop and cause illness Molds/mildew Other. _ _ Utility Company and reference numbers) o o o o o o Unvented Unvented space heater dryer Potential Hazards Found: o o o o o Flue gas spilling into conditioned Prolonged Potential explosive condition space might result in elevated CO levels.Residential Energy Affordability Partnership Program Project No.doc _ . Required Actions: o o o CI. ~j(e Custom r Name /0. Inc. o Heater not drafting ~ High CO level in Furnace/Boiler High CO level in DHW vent High CO level in oven/stove High Ambient CO level o Notified (Provide date/time o o o Waterflooding Unsafe electrical Infestation: Other: In basement wiring. Health and Safety Conditions Found: o o Furnace/Boiler Water vent not drafting o Gas Leak.001_ Health and Safety Acknowledgement. No guarantees are made or implied that all have been found. City State ZipCade The conditions such conditions indicated below were observed during a limited: inspection process.ean/Repair Furnace/Boiler Clean/Repair Have Furnace/boiler vent and/or chimney chimney Water heater vend and/or o o Clean oven/stove Remove unvented Have flooding Heater corrected ___ in basement o Notes: serviced to reduce CO levels Have Hot Water Heater serviced to reduce CO levels o o o Get landlord to correct condition Other: DANE WARREN REAP Field Technician Name Customer's I understand Signature of Acknowledgement for having any conditions checked above corrected. I also understand the potential: "-(0 REA Field Technician Signature Date -II that I am responsible hazards associated with those conditions. to notify (Me Energy Services. and schedule my next site visit. After they have been corrected and that my next site-visit will not be scheduled I will call until these conditions have been corrected.1/ Date REAP 05. location.

5. Exposed masonry walls c. . 0 Low 0 High 0 Medium ~sured/7. 8. Foundation construction/insulation a. Buffered walls ( all types) d.)_ .oo4_lnitial Data Collection Form. Slab REAP_04.doc c:r-r::JY'e 0 (3""'~e. 10. 9.$--OCFM50 (Blower door testing must be done when air and duct sealing is completed) Thermal boundary construction/insulatio~ a.on o Platform / ctHeated basement 0 Garage/other of home This dwelling has floors that are over (check all that apply) o Unheated basement 0 Unheated crawlspace Heated crawlspace 0 Slab 0 Overhang o 6. BUILDING MODEL 1. 7. Basement masonry walls b.{ Number of conditioned floors? Average ceiling height Conditioned volume Infiltration: y 5 r x Width f:(D6.Initial Data-Collection Project No. ~NoyD ~ne sm i san ~Rll 0 Rll+ 0 Rll+ 0 Rll+ 0 unknown 0 unknown 0 unknown 0 0 Rll + 0 unknown 0 ~Rll /' 0 ~ne ct'~ne LiNone ~1l 0 Rll+ 0 unknown 0 unknown 0 ~R11 0 Rll+ 0 ~R1 Page 3112 . The direction the front of the building faces 0 NONE 0 E 0 SE 0 S 0 SW 0 W ~ There is another dwelling attached to the following surfaces (check all that apply): o Above 0 Below 0 Front 0 Back 0 Left 0 Right o None The following walls are at least partially buffered by an unconditioned space{check all that apply): Front 0 BACK 0 LEFT 0 RIGHT o This dwelling has walls that are (check all that a~ o Wood frame 0 Masonry m~ll. 3.or Length /. 2. Crawlspace masonry walls c. Exposed floors 16. Exposed wood frame walls b. 4. Square footage= 3.

Printer(s)-w/PwrSvr Pump{s)-Pool Pump(s)-Sump Pump(s)-Well Television(s) Lg (>24'''') I Clothes Dryer(s)-Electric Clothes Dryer(s)-Gas Clothes Dryer(s) Propane I ~ Clothes Washer I Computer(s) Dehumidifier(s) (include al/ bulbs throughout the interior and exterior of home) -----:.Initial Data Collection Project No.18") ::.:". aI/fields MUST be filled in) Oven/Range(s)-Propane Printer(s)-w/o PwrSvr .~< • Number Number Identify At what temperature do you typically set your thermostat during the summer months? (If your cooling system has more than one thermostat r choose the setting of the thermostat that cools most of your home.doc Page 4112 . D D Central NA/ Barrier Code: by room controls o Multiple of of Zones 0 Room < .64 o under 18 • Number of bathrooms O<.) Weekdays Weekends Daytime Daytime Evening Evening oF of Overnight Overnight of of At what temperature do you typically set your thermostat during the winter months? (If your heating system has more than one thermostat r choose the setting of the thermostat that cools most of your home._ WALK THROUGH the total quantity Air Purifier(s) Aquarium(s) Attic Fan(s) of the following ___ ___ ___ ___ ___ ___ ~ items in the home? (If item is not present indicate Electric Blanket(s) Electric Pool Heater(s) Fax machine(s) Heated Water Bed(s) Hot Tub(s) Humidifier(s) Light Bulbs in Home ___ ~ __ ___ ___ ___ ___ ___ 0..--0/0" Dishwasher(s) NOTES I Oven/Range(s)-Gas WALK THROUGH REAP_04-oo4_lnitial Data Collection Form.) Weekdays Weekends ~ Daytime Daytime a F F Evening Evening a F Overnight Overnight a F F a of o DEMOGRAPHICS of people in the home: of bedrooms B7s'or over I D 18 ..---_Television(s) Md (18-24) / ___ Oven/Range{s)-Electric '3 I Television(s) SM (.. THERMOSTAT SETTINGS Existing thermostat Control Area: is .

ft. it must be documented MECHANICAL VENTILATION NOTES ELECTRlCAL Electrical wiring . DYes. o No o No If work is completed DYes.. fill in number of Insulation Required? If yes. sq. D No DYes [3-'s o No DYes.Pass 0 Fail GA-> (5 Indoor Ambient Temp: U-F :L. ft. . sq. man hrs sq.hhJ lr"'/.L_2/(ppm) Gas leak: Q./ (ppm) ~s 0 Fail Notes: -------------------------------------------------------------------------D Incorrect Venting D Mold/Mildew/Rot D Condensed Moisture D Bulk Water Moisture Conditions Observed: (Check all that apply) D Inadequate Venting Description Other H&S Conditions Observed: Description (Check all that apply) 0 IAQ 0 Electrical 0 Structural o Sewer 0 Other REAP_04'004_lnitial Data Collection Form..'W CFM Man Hours D No DYes... MECHANICAL VENTILATI.Initial Data Collection Project No. sq. on a duct repair/insulation form *2 Man hours and square footage are for informational purposes only.Check all that apply: D Fuses Any rewiring in the past 10 years? DYes ircuit Breakers D Knob & Tube D Romex D BX HEALTH & SAFETY TESTS Outdoor Ambient CO: Oven/Range 0 ppm Outdoor Ambient Temp: ppm :5 0 of 3~ __ . ·2 o No o No DNO~ 0 Yes man hrs D No DYes.. man hrs D No DYes. ft.. D No DYes.ON Vented to the outside? Repair Required? If yes. ft. (ppm) Indoor Living Area Ambient CO: Fuel Burners CO (ppm): 1 Oven CO: __.. man hrs D No DYes. fill in "2 Square Feet Equipment Bathroom Fan N21 Bathroom Fan N22 Oven/Range Fan Dryer Exhaust Duct Material vJ>. (ppm) ~ 2 Y(ppm) D Fail 4 2- .doc Page 5112 .

Q s: crP~ 0 jZc//'/"C(C- /" Test Out Fail o Pass 0 Fail ppm CYP?6S 0 Fail ppm 0 Pass 0 Fail ppm 0 Pass 0 Fail Pa 0 Pass 0 Fair D)' I e.· Initial Data Collection Project No.J.. /i SiN ..".LL t) o Pass 0 Fail ppm [3'P9SS 0 Fail ppm Fail 1Pa lYPass 0 Fail Venting/f Distribution Year of Mfg. ppm 0 Pass 0 Fail Pa 0 Pass 0 Fail - o Pass 0 o Pass 0 Fail ppm 0 Pass 0 Fail ppm 0 Pass 0 Fail Pa 0 Pass 0 Fail BTU.. ].C"( Type FUrl1 BTU.AI"'A ._ Distribution Ret.doc Page 6112 ./ c:(P~ 0 Fail Test Out co Flue: CO Ambient: Draft: . Fuel Detail Venting Distribution Year of Mfg..t.2f!!!$ Worst Case Pressure WRTO: Gas Leak: '0 Yes 0 No Notes: '.{o'lo frCjt.ZPa Test Out Pa Pa Pa _ 8/7Pa Pa Test In Test Out ppm ppm ppm ppm co: ~ ._ Year of Mfg. r-t. 'rn~ 'c 5/.. HEATING & AIR CONDITIONING (_AZPressure Diagnostics Baseline Pressure WRTO: Worst Case Pressure WRTO: Pressure Difference: Notes: Combustion Safety test in (Tested at worst case) CAZ Ambient Test In 'O. llv.:fiE- m~D ppm 0 Pass 0 Fail ppm 0 Pass 0 Fail Pa 0 Pass 0 Fail 5/1'1 -- j'1q/JP- )3o(/L q 301/6"5-1/ . . 49 Spillage: Type BTU. 0 Spillage: CO Flue: CO Ambient: Draft: Notes: Test In A/l~r"~ 1... Fuel Detail < m"._ s-.. L .Jr.d<1ro L/O/C '0// 110 r i Test In Spillage: .5 ::<'fj4! s . 8 Combustion Location Appliance No.2..-. Notes: fJ1vJe/ . Mt.Pa lM"Pass 0 Fail . 8DHWO Location /S/JS'( Type co Flue: CO Ambient: Draft: Notes: " ppm 0 Pass 0 Fail .A-}L13~ Test In ~0(3(-095Cl.......- . Fuel Detail Venting /11/'0/) /J'rpAo3p k./'j Test Out Fail .'~ REAP_04-004_lnitial Data Collection Form.e/- ppm 13"P~ 0 Fail -1/. Ve lot "~ I /:!/leer1. CombustlonAppliance Location No.

D No DYes. sq. ft. ft.Offioe/ tudy.Cellar/crawl. ft. ~Yes. Ifwork is completed it must be documented on a duct repair/insulation form DUCT NOTES REAP_04-o04Jnitial Oata Collection Form.-_. sq. man hrs Man hours and square footage are for informational purposes only. location Attic Crawl/Base Walls "2 Location D Unconditioned D Unconditioned D Unconditioned is . fill in "2 Square Feet D No DYes.doc Page 7112 .livingRoom._--_. Type locatio~ Code·1 C4--( Age Size in STUs ~t: ICD % load % Space SEER /00 "1 locationCodes: Attic. other. D Conditioned D con~ned flK'6nditioned DNo Repair Required? If yes..FamilyRoom. ~o DYes. sq._-------- Initial Data Collection AIR CONDITIONING Project No.Kitchen. man hrs man hrs Insulation Required? If yes. DN~S. Work Area/Shop s IF CAC - Provide data about ducts below ~ ".Exterior. Bedroom. fill in number of "2 Man Hours DYes._-----..-------_.

naccessible. INSULATION EXTERIORWAllS Location (Sketch Reference) Existing Insulation Height Length Condition DYes *3 '4 Sectic:fn lor All *3 !VI/! Section 2 Section 3 Section 4 Section 5 Section 6 Value of Insulation Recommended? (Approximate 4 o No o Yes.- the following if recommending Siding Type V Codes 8 *7 on Sketch? 0 None o No Access Bypass Codes' on Sketch? DYes 0 None 0 No Access '5 Attic Type codes: . Wall Tops. <3" R-value 9 Siding Type Code's: AsbestosAl urninumAsphalt Brick Masonite stucco Wood vinyl other ATTIC location (Sketch Reference) Attic Type Code Existing Insulation Section Condition DYes Value *5 of Insulation JC.5(". 6 . >10 inches R-value"Z4. plumbing Stacks. Floored. s Damage. open/Unfloored. Open Dropped eiling..Kneewa". 9 -12" R-value 24.9 " R-value 19. Garage eiling C *6 *4 *7 '8 Insulation Values (Attic): > 12 inches R-value"29. MinorDamage. Complete ~( . Bypasses Codes: Flue Stacks. C AtticHatch. ther o REAP_04-o04_lnitial Data Collection Form. obstructions. Overhang. Complete the following if recommending (Approximate to nearest foot) to nearest foot) Siding Type Codes on Sketch? 0 None 0 No Access Insulation Values (Exterior Walls). tructural leak. <3" R-value 9 Siding Type Codes: AsbestosALuminum AsPhalt BriCkMasonite stUCCD WODd vinyl other Condition Codes: Existlng priorleak. *6 Section lor All Section 2 Section 3 Section 4 Section 5 Section 6 Recommended? Area (Square Feet) *4 o No /211 All /' r:9"'Yes. customer willclear chasewavs.Initial Data Collection Project No. 3 -5 " R-value 14. Finished slope. 3 -5" R-value 14. 6 -9 « R-value 19.dec Page 81n .

0 -t- 1"3 1'3 /3 0/ 7' z_ 9 10 11 12 13 14 15 16 17 18 19 20 Total Retrofits: *9 Location Bathroom Toilet Bedroom Dining Room Exterior Family Rm/Sitting Rm/Den Hallway Kitchen Living Room Office/Study Pore hiM ud room/U nheated Unlisted/Other Cellar Work Area/Shop 37 Code T B D E F H K L 0 P U C W REAP_04-oo4_lnitial Data Collection' Form.Initial Data Collection Project No.??o sC(-o 4- 4 4-- 4 C:ZCJlJ /3 s= IZ e.l. ~L/O I"." 7' q 7.doc Page 9112 . INSTALLED MEASURES LIGHTING Screw-In Retrofits Installed Existing Burn Time Retrofits Bulb Watts (Hours per day) Product Description Quantity Location Code*g Quantity 1 2 3 L3 -r !3 vf c.. :5 jr:2_ J'7C- 4 5 6 7 8 .

Quantity:.led? ~ 0 Yes.Initial Data Collection DOMESTIC HOT WATER Project No. Ouantitv o Yes.: measured flow rate= gpm gpm gpm o No o Yes o No DYes. measured flow rate= DNa DNa gpm gpm gpm o Yes o Yes I measured flow rate e I measured flow rate= ApPLIANCES Replaced HVAC Filter? Replaced Wall/Window Cleaned HVAC Filter? Cleaned Wall/Window AC Filter? DNa o Yes.: 0 No o No AC Filter? DNa o Yes. Ouantitv e e e Infiltration Testing and Sealing BM Initial Blower Door Reading Blower Door Reading after duct sealing completed Blower door reading after air sealing completed -------@GM~ @CFM50 -------- ------~- @CFM50 @CFMSO REAP_04-004_lnitial Data Collection Form. New F DHW Temperature Turned Down? ~OriginallY 0 0 Showerheads Showerhead #1 Showerhead #2 Showerhead #3 Aerators Kitchen Bathroom 1 Bathroom 2 Measured Flow Rate of Existing gpm gpm gpm f///r New Installation? New Installation? New Installation? DNa I J1 Indicate IF new units were installed.: measured flow rate :. Pipe Insulation Insta.doc Page 10112 . ft. Ouantitv o Yes. I measured flow rate :. 0 Y2 inch 0 % inches F. ~ gpm gpm gpm New Installation? New Installation? New Installation? 0 No DYes. and provide Type & Measured Flow Rate DYes.

if needed D) Damming: ~-Storage __ -Hatch.:» .[ F.__ -Other E) Air Sealing: -Wall tops LF _cLF LF _ Type Type _ _ _ . (of opening) . Rough opening OR Framed opening (circle). f -existing type r:{5 ~ -proposed R-value/Z3 -walkway existing? /-proposed type5 C-. Height in. _ LF SF) -Cantilever __ .LF(x's height= ----. SIO~C): -existing R-vaJue /Z.15 f\/tJ.__ Chimney Chaseways ~ -Other _ _ _ ExplanationiType Drop Soffits __ -Recessed Lights quantity F) Venting needed: -Bath fans quantity __ -Soffit __ G) Health & Saftey: -Ridge __ -Roof Leaks? -Mold? -K&T? H) HeatingiAC Ducts/Boots? Where? Where? (airtight inserts OR caps) Vented outside? -Other(explain) -Gable __ Where? ------------~ ---------------------------------_ YES I NO _ TypelLocation? -Sealing Measures? Basement Air Sealing Checklist -Bandjoist __ ----> . Width Ill.Attic Air Sealing/Insulation Checklist: A) Attic Access: -insulate /weatherstriP / B) Insulation (note FlatslFloors.LF -Chimney chase __ -Pipe/Wire chaseways -HeatingiAC ducts/Boots (circle one or more) -Door under bilco __ -. __ SF (2" Poly Board wi plywood top needed) size (16" OIC or 24" OIC) C) Eave chutes: quantity.

-/(5 A Attic InsulatIon .blow techniaue Air Sealino PrOQram Measures Air Sealing DuctSealing Domestic Hot Water Pipe Insulation Oomestic HOfWater R·10 Tank Wrap (76 Gallon Size Domestic Hot Water Tank temperature I EA EA LF EA Unit Cost ('tprvf'~'" )/!t/rl-7/~ P/Ie ~~ I ~ ~ 1/ tum down Reh"loerators 15 CF Refrigerator En9rgy Star MDdel wfTop Freezer 18 CF Refrillerator ErerllY Star Model wfTop Freezer 21 CF Refrillerator Energy Star Model wfTop Fre&%sr I EA :.tion .LlPA REAP Program Work Orders to be Issued Customer: Description Insulation Attic Insulation· Attic Insulation· R19 Cellulose R20 to R30 Cellulose open .blow technique Quantify Unit of Measure NOTES: t SF SF I</leew-i.R31 to R38 Cellulose open· blow technique AWc Insulation· Cellulose dense pack under 10" SF SF SF SF Basement Celllnq Insulation .R31 to R38 Cellulose open .R1B Flberalass Wafllnsul.7 -: EA EA I .

. wire shelves vs. Yes I .. The color of the refriger~t?~ that will be provided is: . (Example: In a new model.e.:L.. - L<--<~ II --lo~ Date y II ~ LI PA Representative ~~----------~ /1. would you like the new unit to include one? .> ~(" . I read and understood the Refrigerator replacement information above and I would like the new Refrigerator to be delivered. The auditor showed me a color picture and explained the features of the new Refrigerator (i. I understand that I should not remove the food from my existing unit until the deJiveryman is at my home. ':J.. the fresh or freezer compartments may be different or smaller than my existing unit.Revised 8/1/11 LlPA REAP PROGRAM Customer Refrigerator Checklist and Authorization o The auditor explained to me that the Refrigerator Vendor will be contacting me directly to schedule the delivery and installation of my new refrigerator. the freezer section may be smaller. I understand that he new Refrigerator model are streamlined in design. The auditor measure the size of the existing space and all the doorways leading to the kitchen to make sure the new Refrigerator will fit. Initial Do youllandlord currently have an icemaker installed in the unit we are replacing? If currently installed. but the fresh food compartment may be larger than my existing unit.. . Yes I ®.f::Initial . ) Date 0- . may have smaller outside dimensions than~ model. Regarding delivery of a new Refrigerator. glass shelves etc..~ Biscuit (Circle One) Please initial here to acknowledge color acceptance \____: L--- o o ~I o o o I realize that myoid Refrigerator will be disassembled and recycled and that I will not be able to give it away or get it back after removal.) Left Hand Swing The auditor verified the correct direction of the door swing. \ o o o o Right Hand Swing ~ I realize that although I am receiving a similar size Refrigerator.. and as a result. The auditor explained to me that the Refrigerator Vendor MUST have a Free and Clear Path to and from the Refrigerator..

-00 /' Refrigerator Information: (Height is with hinge) 21 cf: 66 3/4" H x 32 3/4" W x 32 3/4" 0. 60 3/4" Open 18cf: 66 5/8" H x 291/2" W x 321/8" 0. No' ' _. This is % in bigger than the refrigerator depth without the door.l D !Vi 11~6 21 CF WITH ICE (WHITE) 21CF WITH ICE (BISCUIT) NO ICE (WHITE) Left Hand Swing Right Hand Swing GTH21 KCXCC GTH21KBXWW " GTH21KBXCC GTH18HCCWW GTH18HCCCC GTH18HBCWW GTH18HBCCC GTH 16BBXRWW GTH 16BBXRCC D Z :2: ur q 21CF D w o D 21CF NO ICE (BISCUIT) 18CF WITH ICE (WHITE) ::s o..T~I-e<.581/8" Open vrgcf: 613/4" H x 28" W x 31" 0 54 7/8" Ope~ -!:!p /'. UJ cr:: D 18CF WITH ICE (BISCUIT) D~18CF NO ICE (WHITE) Does the Refri erator Door need t removed? D D 18 0 ICE (BISCUIT) _I_Yes _No 15CF NO ICE (WHITE) 15CF NO ICE (BISCUIT) _J « U) 0 Q_ U) Manufacturer/Serial Number: Make/Model: /1Ay?7lj {<'Ie JS-ODD 0 _J UJ Location of Unit to be Removed: " ~ Manufacturer/Serial Number: Make/Model: 0 :2: Location of Unit to be Removed: cr:: MINIMUM DOOR/PASSAGEWAY OPENING LEADING TO REFRIGERATOR LOCATION: --:-::--:-_--:--Inches Location: Front Door Side/Rear Door Interior Passageway (15cf requires 26 % in I 18cf requires 28 in 121cf requires 27 % in.- Refriaerator Order Form I' ii'll/or /(qy/::-Iower Ave Telephone: Account#: _ _ klIISI?? GTH21 KCXWW f- /1-i.) Ice maker present? Shut off valve present? Water line connected? __ __ Yes Yes Yes ..Revised 811 111 Custom-er Name: Address: kO . ..) Notes: _ .

~nderstand that if I have any warranty claims within that one year time period I should contact CMC Energy at 888-203-5262 to schedule a service call. ~nderstand that jf there are any issues with the refrigerator after 1 (one) year.II Customer's Signature of Acknowledgement J/MIlt' Customer Name Custome L.r-"'-: /1-ltJ -f Date . ~nderstand that if I need any replacement bulbs within that one year time period I should contact CMC Energy at 888-203-5262 to schedule the delivery and installation of replacement bulbs.REAP RESIDENTIAL ENERGY AFFORDABILITY PARTNERSHIP Program LIPA Long Island Power Authority Refrigerator Warranty Information Wtunderstand that my new refrigerator will have a 1 (one) year manufacturer's warranty. Field Technician / / -/0 REAPField Technician Name Date . loss of food). it will be my responsibility to purchase them.e. ~derstand that if I need any replacement bulbs after the one year time period. it will be my responsibility t6 pay for service and/or replacement parts and that LlPAwill not be responsible for any costs incurred from such repair or for any losses associated with the refrigerator issue (i. Light Bulb Warranty Information D'~erstand that the compact fluorescent light bulbs installed today have a one (1) year warranty.

-- +--:~---.9 36 00 ~/pm Test STOPtime __ Test STARTtime : __ : __ arn/pm Test STARTtime __ __ ELAPSEDtime : __ : __ arn/pm arn/prn if..----------1····-----··-··-·-···-··----------------------..... ---:-:.-:--.-----.-1--------------..2 REFRIGERATOR No..e:.Pi~oor D S~e-bY-Side [:fTop Freezer /.-.:....1 REFRIGERATOR No.ov.-.....doc Page 21u ........'. - D D Single door o D Side-by-side Top Freezer D Bottom Freezer DYes Frost Free Model? Volume: Room Temp: Test STOP time Test STARTtime ELAPSEDtime l:S}'fes D No Frost Free Model? Volume: 0 No (cubic ft.~d"""""'" D Unconditioned --:-:-:...5cu ft 18 cu ft 021 0 Right 15...te_d+... J- 50arn..) Room Temp: Test STOPtime ~: .. Volume: (cubic ft.:..__ ----'D==-...L£.rh. Make: Make: --:-:--....--.....-----.._: ) __L_: __ ELAPSEDtime arn/prn ..:.v17-! 7 ilQ...__~--L--:-~____f'------+-----.) Room Temp: (cubic ft....5cu ft 0 18 cu ft 0 21 cu ft Hinge: Size: 0 Right OLeft D 15. (.3 Location Location -..:.Freezer D Style: D Single door Side-by-side D Top Freezer D Bottom Freezer ····F~~~t-F~.!=D=--o-v-er-he-'a-te.Initial Data Collection Project No. ... REFRIGERATORS I REFRIGERATOR No..~er~~~!ed --... /fj~ -'--- (Tested kWh) _____ (Tested kWh) _____ (Tested kWh) (ELAPSEDtest time) -'--- (ELAPSEDtest time) -'--- (ELAPSEDtest time) x 24 x x 24 x 24 x 365 = Annual kWh = x 365 = Annual REPLACEMENT 365 kWh Annual kWh REPLACEMENT REPLACEMENT q R~v-e ~s: / Only 0 No D cu ft o Remove Only DYes: Hinge: Size: D 0 No OLeft o Remove Only DYes: Hinge: ~~ OLeft Size: [91"5.-:-. ....e.a...-. D Unconditioned Location This area is D Conditioned D Unconditioned I This area is ~onditionedThi~"~~~~"j's-'L:rC~~dit-..--..5cu ft 0 18 cu ft D 21 cu ft REAP _04-oo4_lnitial Data Collection Form.. .rc I ~uo y »< Serial Number: -.----------Year of Manufacture: Year of Manufacture: Year of Manufacture: Type: D~er Only Refrigerator 1 Freezer o Type:···D·Freezer Only·---········-···---··--·· D Refrigerator 1 Freezer Type: OFreezer Only D Refrigerator 1 Freezer Style: Style: D.--------------1 Model: 12.:.// { 07 --. -- __.:..--. -.d----_ Make: .) --:--------------1- /....Model: Model: /111.~M~d~I?-···LlyesTTNo·--···-········ . 1--..-.:.