Add EPA Card to Account
Please complete the following form to add your EPA Certification information to your account.
Company Name or Name of Account
*
Company Phone Number
*
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Area Code
Phone Number
Name
*
First Name
Last Name
Your Phone Number
*
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Area Code
Phone Number
EPA Certificate Number
*
Email Address
*
Are currently in a JS Branch now trying to purchase refrigerant?
Yes
No
Which Branch location are you at?
Anaheim
Laguna Hills
Long Beach
Santa Ana
You agree to the following:
• This EPA card is good for any purchases on the account, for any runner or buyer on your account, while the card remains on file.• You are authorized to submit this card to us on behalf of your company, and the card holder authorizes you to do this.• Your EPA card remains on file on this account name until a request to remove it is submitted in writing.
Attach a Copy of your Picture ID *
*
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of
Attach a Copy of your EPA Card *
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Your Name *
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Signature
*
Submit
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