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[]
[null,"                                                 Home Performance with ENERGY STAR",{"$nulls":21},"OMB Control No. xxxx-xxxx"]
[null,"Post-Installation Tests and Inspections"]
[null,"[Enter Company Name]"]
[]
[null,"Customer Name:",{"$nulls":21},"Customer Phone Number (h):"]
[null,"Customer Address:",{"$nulls":21},"Customer Phone Number (w):"]
[null,"City, State, Zip:",{"$nulls":21},"Customer Email:"]
[null,"Inspection Date:",{"$nulls":21},"Home Performance Analyst:"]
[]
[null,"Blower Door Test and Ventilation Compliance"]
[]
[null,"Method Used to Determine Building Leakage Standard (check one):",{"$nulls":12},"Bldg Leakage (Test-In):",{"$nulls":4},"CFM50 / ACH",{"$nulls":4},"Bldg Leakage (Test-Out):",{"$nulls":4},"CFM50 / ACH"]
[null,"□","Whole Building Mechanical Ventilation per ASHRAE 62.2 - 2007",{"$nulls":16},"(circle one)",{"$nulls":9},"(circle one)"]
[null,"□","Ventilation Credit for Air Leakage (indicate software used):",{"$nulls":16},"CFM50 / ACH / Mech. Ventilation CFM"]
[null,null,null,"□","TECTITE",null,null,"□","ZipTest Pro2",{"$nulls":10},"(circle one)"]
[null,"□","Ventilation Exemption for Existing Homes per ASHRAE 62.2 - 2007",{"$nulls":11},"□","Pass","□","Pass w/ Ventilation Recommended"]
[null,"□","BPI Legacy Building Air Tightness Std per ASHRAE 62.2 - 1989",{"$nulls":11},"□","Fail -  Action Required:"]
[null,"□","Other:"]
[]
[]
[null,"Combustion Equipment Testing / Combustion Appliance Zone Testing"]
[{"$nulls":4},"Worst Case Test Results",{"$nulls":5},"Natural Condition Test Results"]
[{"$nulls":4},"Spillage",null,"Draft",null,"CO",null,"Spillage",null,"Draft",null,"CO",null,"Flue Inspection"]
[null,null,null,"Heating System 1:","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,"□","Action Required:"]
[null,null,null,"Heating System 2:","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,"□","Action Required:"]
[null,null,null,"DHW System 1:","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,"□","Action Required:"]
[null,null,null,"Other:","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,null,"pa",null,"ppm","Pass   Fail",null,"□","Action Required:"]
[null,null,"CO Ambient",null,"Base Pressure",null,"Worst Case Pressure",null,"Net CAZ Depress.",null,"Limit for CAZ",null,"Result"]
[]
[null,"CAZ 1:",{"$nulls":10},"Pass   Fail",null,"□","Action Required:"]
[null,"CAZ 2:",{"$nulls":10},"Pass   Fail",null,"□","Action Required:"]
[null,null,null,"Gas Leak Testing:","□","No Leaks Detected",null,null,"□","Leaks Detected as Noted:"]
[]
[{"$nulls":4},"Kitchen",null,null,"Main Living",null,null,"Other - ppm"]
[null,null,null,"Ambient CO:",{"$nulls":9},"□","Action Required:"]
[{"$nulls":4},"Fuel",null,null,"CO ppm",null,null,"Vent Out?"]
[null,null,null,"Oven CO:",{"$nulls":6},"  Yes      No",null,null,"□","Action Required:"]
[null,null,null,"Dryer Vent:","□","Electric",null,"□","Gas Properly Vented",null,null,null,"□","Gas Improperly Vented.  Action Required: "]
[]
[]
[null,"Distribution System Air Flow (required if ducts were sealed as part of project) and Leakage Test"]
[]
[{"$nulls":5},"Airflow Test Result:",null,null,"□","Pass","□","Fail",{"$nulls":9},"Duct Leakage Test:","Duct Blaster",null,null,"BD Subtract",null,null,"Delta Q",null,null,"Press Pan"]
[{"$nulls":5},"If fail, action to be taken:",{"$nulls":17},"Duct Test Result (enter here or attach separate form):"]
[{"$nulls":20},"Pressure Pan Average (Test-In):",{"$nulls":8},"Pressure Pan Average (Test-Out):"]
[]
[]
[null,"Verification of Measures Installed:",{"$nulls":5},"□","Attic Stairs Insulation",{"$nulls":6},"□","DHW System Replace / Repair",{"$nulls":7},"□","Health & Safety:"]
[null,"□","Basement Air Sealing",{"$nulls":4},"□","Attic Tent",{"$nulls":6},"□","DHW Blanket / Pipe Insulation"]
[null,"□","Attic Air Sealing",{"$nulls":4},"□","Window Replacement / Repair",{"$nulls":4},"Qty:",null,"□","Exhaust Fans - Qty _____  / HRV",{"$nulls":7},"□","Other:"]
[null,"□","Basebrd / Molding Air Sealing",{"$nulls":4},"□","Window Film / Solar Screen",{"$nulls":4},"Qty:",null,"□","Exhaust Vents Reroute / Insulate"]
[null,"□","Windows / Doors Air Sealing",{"$nulls":4},"□","Door Replace / Repair",{"$nulls":4},"Qty:",null,"□","Attic Vents",null,null,null,"Qty:",null,null,null,"□","Other:"]
[null,"□","Ext. Wall to Garage Air Sealing",{"$nulls":4},"□","Heating System Replace / Repair",{"$nulls":6},"□","Appliance:"]
[null,"□","Attic Flat Insulation",{"$nulls":4},"□","Central Air Conditioner Replace / Repair",{"$nulls":6},"□","Appliance:",{"$nulls":7},"□","Notes/Items Requiring Follow-Up:"]
[null,"□","Attic Slope Insulation",{"$nulls":4},"□","Htg / DHW Flue Replace / Repair",{"$nulls":6},"□","Appliance:"]
[null,"□","Attic Kneewall Insulation",{"$nulls":4},"□","Air Handler Replace / Repair",{"$nulls":6},"□","Lighting:CFL's / Fixt.",null,null,null,"Qty:"]
[null,"□","Exterior Wall Insulation",{"$nulls":4},"□","Duct Sealing / Insulation / Replacement",{"$nulls":6},"□","Renewable Energy Syst: ___________"]
[]
[]
[null,"Contractor Statement and Signature:"]
[]
[null,"I attest that all of the information entered above is correct to the best of my knowledge.  I agree to complete any items noted above for follow-up corrective action, and will submit an additional Post-Installation Tests and Inspections form that verifies the successful completion of those items and records required follow-up tests or inpsections:"]
[]
[null,"Contractor Signature:",{"$nulls":22},"Date:"]
[]
[null,"Customer Statement "]
[]
[null,"I attest that I am the owner of the property specified above, and that all materials and equipment included my home improvement contract with the above Contractor have been furnished and installed by the Contractor, and that the work has been completed pursuant to the contract."]
[]
[null,"Customer Signature:",{"$nulls":22},"Date:"]
[]
[]
[null,"EPA Form 5900-187"]
[null,"The government estimates the average time needed to fill out this form is 1.00 hours and welcomes suggestions for reducing this effort. "]
[null,"Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460."]

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