Technician Form Date Tech Name First Last Customer Name First Last PhoneEmail* Service 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 Service Call TypePMRepairEstimateNotesHome InformationHouse TypeRanch2-Story3-StorySplit-LevelBi-LevelCapeMid-RowEnd-RowDuplexFoundationSlabBasementCrawlspaceBasement InsulationNoneWallsFinishedCrawlspace InsulationNoneWallsCeilingMoisture?YesNoYear BuiltInsulation TypeFiberglass BattsBlown-InOtherNoneNumber of InchesStorageAttic AccessPull Down StairsHatchWater Heater InformationWater Heater LocationWater Heater AgeWater Heater Make/BrandWater Heater GallonsWater Heater TypeTank-StandardTank-High EfficiencyTanklessTankless Back-UpHeat PumpOn DemandIndirectOtherIf other, what?Water Heater FuelNatural GasElectricOilPropaneWater Heater VentingAtmosphericPower VentedSealed CombustionWater Heater Common Vented W/Heat?YesNoHeating System InformationNumber of Heating SystemsHeating System LocationHeating System BTU (Output)Heating System Make/BrandHeating System Model #Heating System Age/YearHeating System TypeFurnaceBoilerElectric ResistanceHeat PumpHeating System FuelNatural GasPropaneOil<1984 Low Speed (1725rpm)>1984 High Speed (3450rpm)Heating System DetailsPilot (~71%)Electronic Ignition (74%)Induced Draft (80%)Condensing (90%)Heating System VentingAtmosphericInduced DraftSealed CombustionCooling System InformationNumber of Cooling SystemsType of Cooling SystemCentral A/CHeat PumpMini-Split DuctlessNoneLocation of Indoor CoilCooling System CapacityCooling System Make/BrandCooling System Outdoor Model #Cooling System Age/YearHydronic Distribution System TypeBaseboardRadiatorSteam PipeRadiantAir/Duct Distribution System TypeRegular VelocityHigh VelocityECM MotorGravityDucts Outside AtticPoorly VentedWell VentedInsulation InformationAttic % SupplyAttic % ReturnAttic R-ValueDucts Outside Vented Crawlspace - Crawlspace Ceiling InsulatedYesNoVented Crawlspace % SupplyVented Crawlspace % ReturnVented Crawlspace R-ValueDucts Outside Enclosed CrawlspaceCrawlspace Ceiling InsulatedCrawlspace Walls InsulatedEnclosed Crawlspace % SupplyEnclosed Crawlspace % ReturnEnclosed Crawlspace R-ValueGarage % SupplyGarage % ReturnGarage R-ValueDucts Inside Conditioned-Basement % SupplyDucts Inside Conditioned-Basement % Return
