Qualification to Produce ENERGY STAR Modular Homes

I, (Name of Certifier)	 , hereby certify that 

(Manufacturer Name)	, located at (Address, City, State)			, 

has demonstrated the capability consistently to produce ENERGY STAR
qualified modular homes and is therefore authorized to apply the SBRA
ENERGY STAR quality assurance label to new homes manufactured under the
terms and conditions of the ENERGY STAR program.

ENERGY STAR Certifier:		Company: 	

Certifier signature: 		Date: 	

Plant contact person: 		Telephone: 	

E-Mail: 				Fax: 	

Certifier must complete the following:

ENERGY STAR design method

(Must check one box below) 

    ENERGY STAR prescriptive design or BOP

Computer analysis (attached) 

ENERGY STAR features incorporated into factory quality assurance
procedures

(Must check all applicable boxes below) 

	Information included in third-party-approved design package

	Information included in plant Quality Control Manual 

	Information included in builder installation instructions

ENERGY STAR modular home checklist

(Must check below) 

ENERGY STAR Modular Home Checklist developed identifying items that must
be verified in the factory and at the building site

Homes inspected and tested in the field 

(Must check below) 

	Three (3) homes meet ENERGY STAR requirements

ENERGY STAR included into routine factory operations

(Must check all boxes below) 

	Corrective actions identified during tests implemented and
documented

	Key plant personnel trained on critical processes and procedures

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葞ц摧ହ¹଀NERGY STAR third-party-approved packages reviewed with
plant’s   	 third-party design approval and inspection agencies

	Process in place for collecting, tracking and archiving
documentation on ENERGY STAR 

Submit this form to SBRA:

	Fax number: 212-496-5389, or 

	Mailing address: 2109 Broadway, Suite 200, New York, NY 10023, or

	E-Mail: info@research-alliance.org

OMB Control No. xxxx-xxxx

Energy Star Modular Homes	Rev.   DATE \@ "M/d/yyyy"  9/17/2009 

EPA Form 5900-194

The government estimates the average time needed to fill out this form
is 0.20 hours and welcomes suggestions for reducing this effort. Send
comments (referencing OMB Control Number) to the Director, Collection
Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460.

