**POLLUTION PREVENTION PROJECT**

**OPTIONAL PRE-SCREENING FORM**

+--------+---------------------------------+--------------------------+
| **S    |                                 | **For Operations Office  |
| ite:** |                                 | Use Only**               |
+--------+---------------------------------+--------------------------+
| **P    |                                 | **Recommended for        |
| roject |                                 | Proposal Submission:**   |
| Ti     |                                 |                          |
| tle:** |                                 |                          |
+--------+---------------------------------+--------------------------+
| **Site |                                 | **YES \_\_\_\_\_ No      |
| Cont   |                                 | \_\_\_\_\_**             |
| act:** |                                 |                          |
+--------+---------------------------------+--------------------------+
| **Ph   |                                 | **WMin/PP Coordinator /  |
| one/** |                                 | Date**                   |
|        |                                 |                          |
| **     |                                 |                          |
| Fax:** |                                 |                          |
+--------+---------------------------------+--------------------------+

**Indicate Project Type:** (check one)

Source Reduction On-Site Recycling Off-Site Recycling Other (specify)

**Project Summary:** Provide 3-5 bullets to describe the project,
include:

1\. Statement of existing process/activity condition; 2. Statement of
proposed change to process/activity;

3\. Brief description of expected waste/pollution reductions.

**Technical Risk:** (circle one)

(Lowest Risk) (Minimal Risk) (Medium Risk) (Highest Risk)

Proven Technology/Methodology Tech. Commercially Available Field
Validation Required Experimental Tech.

**Has this problem been previously evaluated in a PPOA or other
engineering study?**

(If Yes, briefly explain)

**Status of the proposed project** (check one)

Conceptual Engineering Study Complete Prelim. Design Complete

Other (specify)

**To the nearest \$1,000, estimate one-time implementation costs for
this project. \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**To the nearest \$1,000, estimate annual cost savings from implementing
this project. \$\_\_\_\_\_\_\_\_\_\_**

**POLLUTION PREVENTION PROJECT**

**FUNDING REQUEST PACKAGE**

**Project Title :**

**Site/Facility :**

**We certify that the information provided herein is accurate to the
best of our knowledge.**

**The above identified Facility, commits to operate the proposed project
in the years following the original implementation period, so long as
cost savings continue to be realized.**

Division /Organization Manager:
\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Signature Date

> Project Manager:
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Signature Date

Site Pollution Prevention Coordinator:
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Signature Date

**POLLUTION PREVENTION PROJECT**

**DESCRIPTION**

**Project Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**1. [Project Description:]{.underline}**

Describe: 1) The current waste-generating process/activity, and 2) How
the current process/activity will be modified to prevent/recycle waste.
Include assumptions related to the successful completion of the project,
including regulatory issues (i.e., the proposed process/activity will
require a modified permit, etc.)

(Attach additional pages as needed to present the relevant information.)

**2. [Description of Benefits:]{.underline}**

a\) Waste reduction information by category (RCRA, TRU, SLLW, LLLW,
Process Waste Water etc.)

+----------+--------------+-------------+-------------+--------------+
| **Waste  | **One Time   | **Waste     | **Air Emis. | **ER Only:** |
| Ca       | Waste        | Reduced     | Only:**     |              |
| tegory** | Reduction    | Annually    |             | **Kg Gen     |
|          | (in Kgs)**   | (in Kgs)**  | **Kg Gen    | Annually     |
| **&      |              |             | Annually    | Before P2**  |
| Descr    |              |             | Before P2** |              |
| iption** |              |             |             |              |
+----------+--------------+-------------+-------------+--------------+
|          |              |             |             |              |
+----------+--------------+-------------+-------------+--------------+
|          |              |             |             |              |
+----------+--------------+-------------+-------------+--------------+
|          |              |             |             |              |
+----------+--------------+-------------+-------------+--------------+
|          |              |             |             |              |
+----------+--------------+-------------+-------------+--------------+
|          |              |             |             |              |
+----------+--------------+-------------+-------------+--------------+

b\) Other benefits (i.e., increased process/activity efficiency,
decreased worker risk, etc.)

**POLLUTION PREVENTION PROJECT**

**DESCRIPTION (Continued)**

**Project Title:**

**3. [Project Schedule, Milestones, and Deliverables:]{.underline}**

Using a rough time line indicate the major tasks, milestones, and
deliverables involved in the completion of the project. Indicate number
of months from funding to each milestone and deliverable. (Use
additional pages as needed.)

**4. [Comments:]{.underline}** (Use this space, as necessary, to qualify
relevant aspects of the project not included above.)

**POLLUTION PREVENTION PROJECT**

**DESCRIPTION (Continued)**

**Project Title:**

**5. [System/Process Flow Diagram:]{.underline}**

Show:

\(1\) Flow diagram of the current process/activity, and

\(2\) Flow diagram of the proposed process/activity.

**POLLUTION PREVENTION PROJECT**

**Worksheet 1: PROJECT IMPLEMENTATION BEFORE & AFTER COSTS**

+-------------------------------------+----------+---------+---------+
|                                     | **       | BEFORE  | **      |
|                                     | Before** | costs   | After** |
|                                     |          | refer   |         |
|                                     |          | to      |         |
|                                     |          | a       |         |
|                                     |          | nnually |         |
|                                     |          | re      |         |
|                                     |          | curring |         |
|                                     |          | costs   |         |
|                                     |          | for the |         |
|                                     |          | CURRENT |         |
|                                     |          | pro     |         |
|                                     |          | cess/ac |         |
|                                     |          | tivity. |         |
|                                     |          |         |         |
|                                     |          | AFTER   |         |
|                                     |          | costs   |         |
|                                     |          | refer   |         |
|                                     |          | to      |         |
|                                     |          | a       |         |
|                                     |          | nnually |         |
|                                     |          | re      |         |
|                                     |          | curring |         |
|                                     |          | costs   |         |
|                                     |          | AFTER   |         |
|                                     |          | the     |         |
|                                     |          | p       |         |
|                                     |          | roposed |         |
|                                     |          | P2      |         |
|                                     |          | project |         |
|                                     |          | has     |         |
|                                     |          | been    |         |
|                                     |          | imple   |         |
|                                     |          | mented. |         |
|                                     |          |         |         |
|                                     |          | Refer   |         |
|                                     |          | to the  |         |
|                                     |          | AGuide  |         |
|                                     |          | to      |         |
|                                     |          | E       |         |
|                                     |          | stimate |         |
|                                     |          | and     |         |
|                                     |          | Re      |         |
|                                     |          | porting |         |
|                                     |          | Po      |         |
|                                     |          | llution |         |
|                                     |          | Pre     |         |
|                                     |          | vention |         |
|                                     |          | costs   |         |
|                                     |          | B       |         |
|                                     |          | enefits |         |
|                                     |          | for the |         |
|                                     |          | Oak     |         |
|                                     |          | Ridge   |         |
|                                     |          | Reser   |         |
|                                     |          | vation, |         |
|                                     |          | Paducah |         |
|                                     |          | and     |         |
|                                     |          | Port    |         |
|                                     |          | smouth, |         |
|                                     |          | July    |         |
|                                     |          | 1995\", |         |
|                                     |          | (pages  |         |
|                                     |          | 7-14)   |         |
+-------------------------------------+----------+---------+---------+
| **Expense Cost Items**              | **       |         | **A     |
|                                     | Annual** |         | nnual** |
| Attach additional sheets to         |          |         |         |
| identify sources and document all   | **R      |         | **Re    |
| calculations                        | ecurring |         | curring |
|                                     | Costs**  |         | Costs** |
+-------------------------------------+----------+---------+---------+
| 1\. Equipment                       |          |         |         |
+-------------------------------------+----------+---------+---------+
| 2\. Purchased raw materials and     |          |         |         |
| supplies                            |          |         |         |
+-------------------------------------+----------+---------+---------+
| 3\. Process Operation Costs:        |          |         |         |
+-------------------------------------+----------+---------+---------+
| A.. Utility costs (see Table 2\*)   |          |         |         |
+-------------------------------------+----------+---------+---------+
| B. Labor costs                      |          |         |         |
+-------------------------------------+----------+---------+---------+
| C. Routine Maintenance costs for    |          |         |         |
| processes                           |          |         |         |
+-------------------------------------+----------+---------+---------+
| 4\. PPE & related health/safety     |          |         |         |
| supply costs                        |          |         |         |
+-------------------------------------+----------+---------+---------+
| 5\. Waste Management Costs:         |          |         |         |
+-------------------------------------+----------+---------+---------+
| A. Waste container costs            |          |         |         |
+-------------------------------------+----------+---------+---------+
| B. Treatment/Storage/Disposal Costs |          |         |         |
| (See Table 1\*)                     |          |         |         |
+-------------------------------------+----------+---------+---------+
| C. Inspection/Compliance costs      |          |         |         |
+-------------------------------------+----------+---------+---------+
| 6\. Recycling Costs                 |          |         |         |
+-------------------------------------+----------+---------+---------+
| A.. Material                        |          |         |         |
| collection/separation/preparation   |          |         |         |
| costs:                              |          |         |         |
+-------------------------------------+----------+---------+---------+
| 1\. Material and supply costs       |          |         |         |
+-------------------------------------+----------+---------+---------+
| 2\. Operations and maintenance      |          |         |         |
| labor costs                         |          |         |         |
+-------------------------------------+----------+---------+---------+
| B. Vendor costs for recycling       |          |         |         |
+-------------------------------------+----------+---------+---------+
| C. Revenue from recycling (enter as |          |         |         |
| a negative number)                  |          |         |         |
+-------------------------------------+----------+---------+---------+
| 7\. Administrative/Other costs      |          |         |         |
+-------------------------------------+----------+---------+---------+
| **Total Annual Cost: Before (B)=**  |          | **After |         |
|                                     |          | (A)=**  |         |
+-------------------------------------+----------+---------+---------+

**\***Located in the AGuide to Estimating and Reporting Pollution
Prevention Cost Benefits for the Oak Ridge Reservation, Paducah and
Portsmouth, July 1995\".

**POLLUTION PREVENTION PROJECT**

**WORKSHEET 2: ITEMIZED PROJECT FUNDING REQUIREMENTS**

(One Time Implementation Costs)

(Refer to AGuide to Estimating and Reporting Pollution Prevention Cost
Benefits for the ORR, Paducah and Portsmouth, 7/95, pgs 15-21\")

+------------------------------------------------------+---------------+
| **Category**                                         | **Cost \$**   |
|                                                      |               |
| (Use additional sheets to identify sources and       |               |
| document all calculations)                           |               |
+------------------------------------------------------+---------------+
| **INITIAL CAPITAL INVESTMENT GPE: GPP: (Mark, as     |               |
| applicable)**                                        |               |
+------------------------------------------------------+---------------+
| 1\. Design (only if GPP and Title 1 or 2)            |               |
+------------------------------------------------------+---------------+
| 2\. Purchase\* (material procurements + 8.75% sales  |               |
| tax)                                                 |               |
+------------------------------------------------------+---------------+
| 3\. Installation (include removal costs if           |               |
| applicable)                                          |               |
+------------------------------------------------------+---------------+
| 4\. Procurement Charge (generally 3% of purchase     |               |
| cost)                                                |               |
+------------------------------------------------------+---------------+
| 5\. Contingency (generally 5% of purchase cost)      |               |
+------------------------------------------------------+---------------+
| 6\. Overhead (46.9% of installation, procurement,    |               |
| and 1st \$5000 of purchase costs)                    |               |
+------------------------------------------------------+---------------+
| **Subtotal: Capital Investment = (C)**               |               |
+------------------------------------------------------+---------------+
| **OPERATING OR STARTUP EXPENSES**                    |               |
+------------------------------------------------------+---------------+
| 1\. Planning/Procedure Development                   |               |
+------------------------------------------------------+---------------+
| 2\. Training                                         |               |
+------------------------------------------------------+---------------+
| 3\. Misc. supplies                                   |               |
+------------------------------------------------------+---------------+
| 4\. Startup/Testing                                  |               |
+------------------------------------------------------+---------------+
| 5\. Readiness reviews/ Management assessment/        |               |
| Administrative costs                                 |               |
+------------------------------------------------------+---------------+
| 6\. Other installation operating expenses (explain)  |               |
+------------------------------------------------------+---------------+
| 7\. Overhead                                         |               |
+------------------------------------------------------+---------------+
| **Subtotal: Installation Operating Expenses = (E)**  |               |
+------------------------------------------------------+---------------+
| **TOTAL PROJECT FUNDING REQUIREMENTS = (C + E)**     |               |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+
| Useful project life = (L) years Time to Implement:   |               |
| months                                               |               |
+------------------------------------------------------+---------------+
| Estimated Project Termination/Disassembly Cost (if   |               |
| applicable) = (D)                                    |               |
|                                                      |               |
| (Only for projects where L \<= 5 years; D = 0 if L\> |               |
| 5 years)                                             |               |
+------------------------------------------------------+---------------+
| **[Return on Investment Calculation]{.underline}**   |               |
|                                                      |               |
| Return on Investment (ROI) % = [\[Before - After\] - |               |
| {\[Total Project Funding Requirements + Project      |               |
| Termination\] / Life}]{.underline} x 100%            |               |
|                                                      |               |
| \[Total Project Funding Requirements + Project       |               |
| Termination\]                                        |               |
|                                                      |               |
| **ROI%** = [\[B - A\] - { \[C + E + D\] / L          |               |
| }]{.underline} x 100 = %                             |               |
|                                                      |               |
| \[C + E + D\]                                        |               |
+------------------------------------------------------+---------------+
| Notes: Before (B) and after (A) are Operating &      |               |
| Maintenance Annual Recurring Costs from Worksheet 1  |               |
+------------------------------------------------------+---------------+

\* List each item being purchased on separate sheet. Enter total
purchase including sales tax on worksheet. Do not include costs for
design, installation, overhead, procurement, or contingency as these are
listed separately.