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Coffee Roaster Notification

  1. Only for batch roasters with a maximum rated capacity of 10lb/batch or less

  2. AGENCY USE ONLY

  3. Date

  4. Registration No.

  5. Notification No.

  6. FACILITY INFORMATION

  7. Business Hours

  8. EQUIPMENT INFORMATION

  9. Manufacturer

  10. Is the roaster electric?

  11. Is the roaster controlled by an afterburner or catalytic oxidizer?

  12. CERTIFICATION

  13. I, the undersigned, do hereby cerify that the information contained in this notification is, to the best of my knowledge, accurate and complete.

  14. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  15. You must pay a $200 filing fee to complete this application. Please select an option for payment below.

  16. Leave This Blank:

  17. This field is not part of the form submission.