5900-265 Plant Award Specification Sheet

Plant Award
Specification Sheet
The data on this form is used for generating certification materials, which includes a certificate for each plant and a letter to the
Corporate Energy Manager (CEM) and Chief Executive Officer (CEO). Complete this form with company and plant names and
contact information as it should be referenced on certification materials. The letters to the CEO will reference the plants that
received certification and will acknowledge the CEM for helping reduce energy use. If any other staff should be acknowledged,
please write their names and titles at the end of the form. For multiple plants that fall under the same CEO and CEM input
additional plants on page 2. For multiple plants with a different CEO or CEM use a separate form. OMB Control No. 2060-0347

Corporate Energy
Manager
Name
Title
Company
Address 1
Address 2
City, State, Zip
Email
Phone
Company
Address
City, State, Zip
Email

Corporate
Communications
Contact

Organization’s Chief
Executive Officer

Plant Owner (complete if different from CEO contact information)

Plant 1 – As it should appear on certificate
Plant name
Company name
Address 1
Address 2
City, State, Zip
Plant Contact (Name, title, email)
Decal type (see below)
What did the plant do this past
year to maintain or improve its
energy performance?*
ENERGY STAR Decals
Cyan and
Etched
White

Cyan and white☐

Etched☐

All hardcopy recognition material is sent as one package to the CEM at the location specified
above. The congratulatory letter for the CEO will be sent directly to the address provided for
the CEO. Electronic notification of certification will be sent to the CEM , plant contacts, and to
the person who sent the application. Please specify any other distribution requests in the
space below.

Additional people to acknowledge in letter:
Recipient for hardcopy recognition materials (if different from CEM):
Additional people to notify electronically:

February 2020

The public reporting burden for this collection of information is estimated to range up to 15 minutes per response. Send comments
on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for
minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies
Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the
OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form 5900-265

Plant Award
Specification Sheet

Plant 2 – As it should appear on certificate
Plant name
Company name
Address 1
Address 2
City, State, Zip
Plant Contact (Name, title, email)
Decal type (see below)
What did the plant do this past
year to maintain or improve its
energy performance?*

Cyan and white☐

Etched☐

Plant 3 – As it should appear on certificate
Plant name
Company name
Address 1
Address 2
City, State, Zip
Plant Contact (Name, title, email)
Decal type (see below)
What did the plant do this past
year to maintain or improve its
energy performance?*

Cyan and white☐

Etched☐

Plant 4 – As it should appear on certificate
Plant name
Company name
Address 1
Address 2
City, State, Zip
Plant Contact (Name, title, email)
Decal type (see below)
What did the plant do this past
year to maintain or improve its
energy performance?*

Cyan and white☐

Etched☐

*Optional, used for identifying success stories.

The public reporting burden for this collection of information is estimated to range up to 15 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and
any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do
not send the completed form to this address.
EPA Form 5900-265