2. Only for batch roasters with a maximum rated capacity of 10lb/batch or less
4. AGENCY USE ONLY
6. Date
7. Registration No.
8. Notification No.
12. FACILITY INFORMATION
14. Facility Name
15. Registration No.
17. Mailing Address
19. City
20. State
21. Zip Code
23. Installation Address
25. City
26. State
27. Zip Code
29. Contact Person
30. Email Address
32. Address (if different than above)
34. City
35. State
36. Zip Code
38. Phone Number
39. Fax Number
41. Business Hours
42. Hours per Day
43. Days per Week
44. Weeks per Year
46. Estimated Installation Date
    Estimated Installation Date
50. EQUIPMENT INFORMATION
52. Manufacturer
53. Make
54. Model
55. Airflow (cfm)
57. Maximum rated batch size (lb/batch):
59. Maximum monthly production (lb/month)
61. Is the roaster electric?

    1. Yes
    2. No
62. If no, what fuel is used to heat roaster?
64. Is the roaster controlled by an afterburner or catalytic oxidizer?

    1. Yes
    2. No
65. If yes, what is the Make/Model?
66. What is the burner rating?
70. CERTIFICATION
72. I, the undersigned, do hereby cerify that the information contained in this notification is, to the best of my knowledge, accurate and complete.
74. Name
75. Phone Number
76. Date
    Date
78. 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.

    1. I agree.
80. Electronic Signature
82. You must pay a $200 filing fee to complete this application. Please select an option for payment below.

    1. Pay by Check (print a copy of this application and mail with check)
    2. Pay by Credit Card (an accounting technician will contact person listed below for payment information)
84. Contact Person for Credit Card Payment
85. Contact Phone Number
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit Submit and Print

* indicates a required field