5900-264 Plant Award Application Letter

OMB Control No. 2060-0347

The text from the letter below can be pasted into an email, or printed on company letterhead, scanned
and sent electronically with accompanying documents to certifiedplants@energystar.gov. Do not mail
hard copy applications.
[DATE]
ENERGY STAR for Industry
U.S. Environmental Protection Agency
1200 Pennsylvania Avenue, NW
Mail Code 6202A
Washington, DC 20460
Dear ENERGY STAR for Industry:
As the corporate energy director for [name of company], I am writing to nominate the following plant(s) for
award of the [Year] ENERGY STAR:
[Plant name]
[Plant street address]
[Plant city, state, zip code]
[Repeat for additional plants-all plants with certification applications can be included on one letter]
As documented by the attached Statement of Energy Performance, I affirm that the aforementioned plant
meets the conditions necessary to qualify for the ENERGY STAR, including an Energy Performance Score in
the top quartile of the most current version of the ENERGY STAR Energy Performance Indicator for this type
of plant, or for petroleum refineries, scoring within the top quartile of the Solomon-EII™ scoring system.
I have personally examined and am familiar with the information contained in this Application. The
information is based on reasonable inquiry and is, to the best of my knowledge, true, accurate, and complete. I
have no reason to believe the plant would not meet all EPA program requirements for receiving the ENERGY
STAR.
I am submitting this application within one year of the period ending date on the enclosed Statement of
Energy Performance. I understand EPA reserves the right to request and review any records which support the
data used to produce the Energy Performance Score for this plant. I also certify that I am maintaining a formal
certification file on this plant in accordance with EPA’s formal certification file requirements. Furthermore, I
agree to associate the ENERGY STAR name and logo only with the aforementioned plant and to adhere to
ENERGY STAR’s Identity Guidelines.
Sincerely,
Signature__________________________
Signatory Name (Corporate Energy Manager for [Company name]):_________________
Attachments: Statement of Energy Performance, EPI Printout, Award Specification Sheet, PE Verification
Checklist

The public reporting burden for this collection of information is estimated to range up to 10 minutes per response. Send com ments on the
Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent
burden, including throughthe use of automated collection techniques to the Director, Collection Strategies Division, U.S. En vironmental
Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB contro l number in any
correspondence. Do not send the completed form to this address.
EPA Form 5900-264