Point of Origin Form Customer InformationCustomer Name*Contact Name*Address:*City:*State:*Zip Code:*Email:*Telephone:* Refrigerant InformationRefrigerant Category:*Please SelectCFCHFCRefrigerant:*Please SelectR-11R-12R-13R-13B1R-113R-114R-500R-502R-503Refrigerant:*Please SelectR-23R-32R-116R-125R-134aR-236faR-245faR-404AR-407AR-407CR-407FR-410AR-417AR-417CR-421AR-422AR-422BR-422DR-427AR-438AR-507R-508AR-508B System Site (for system recoveries)Facility Name:*Facility Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Federal Government Facility?*YesNo Identification of SystemSerial/Model Number:Equipment Description: if serial number is not available:Manufacturer Name:*Location of System Inside the Facility:* Recovery InformationCompany Performing Recovery:*Recovery Date:* Estimated Pounds Recovered* Technician InformationName of Recovery Technician:*EPA Certification Type:*Type IType IIType IIIUniversalEPA 608 License #:*Technician Employer:*UntitledEmployer Contact and Phone #:* Stockpile Information (if not a recovery)Address of CFC Stockpile:Number of Years in Possession:Stockpile Documentation Available (Original PO, Inventory Records, etc)?Letter of Attestation Needed?YesNo Cylinder InformationCylinder Size(s):* 30/50 lb 125 lb 240 lb 1/2 ton Other # and Size of Each Recovery Cylinder:*Serial # of Recovery Cylinder(s):*Number of Skids*File Upload (Proposal Received from Account Manager)Accepted file types: pdf. This iframe contains the logic required to handle Ajax powered Gravity Forms.