Point of Origin Form – Hudson Technologies

Customer Information

Customer Name*

Contact Name*

Address:*

City:*

State:*

Zip Code:*

Email:*

Telephone:*

Refrigerant Category:*

Refrigerant:*

Facility Name:*

Facility Address:*

Street Address Address Line 2 City State ZIP Code

Federal Government Facility?*

Serial/Model Number:

Equipment Description: if serial number is not available:

Manufacturer Name:*

Location of System Inside the Facility:*

Company Performing Recovery:*

Recovery Date:*

Estimated Pounds Recovered*

Name of Recovery Technician:*

EPA Certification Type:*

EPA 608 License #:*

Technician Employer:*

UntitledEmployer Contact and Phone #:*

Address of CFC Stockpile:

Number of Years in Possession:

Stockpile Documentation Available (Original PO, Inventory Records, etc)?

Letter of Attestation Needed?

Cylinder Size(s):*

# and Size of Each Recovery Cylinder:*

Serial # of Recovery Cylinder(s):*

Number of Skids*

File Upload (Proposal Received from Account Manager)