OMB Contr ol No. 2060-0578 Appr oval Expir es 04/30/2009 

# Par tner’ s Letter of Intent for State, Local, T r ibal Agencies With this letter ________________________________________________________ (State/Local/T r ibal Agency) joins EP A's Combined Heat and Power (CHP) Partnership and commits to work with EP A to pr omote the benefits of CHP and support development of new CHP pr ojects within our state/locale. Sincer ely, __________________________________________________________________________________ Author ized State/Local/T r ibal Agency Repr esentative Signatur e Name: _____________________________________________________________________________________ Title: ___________________________________________________________ Date: ______________________ 

## The State/Local Par tner Agr ees to: 1. Designate a liaison for EP A's CHP Partnership. 2. Host a workshop to pr omote the benefits of CHP and support development of new CHP pr ojects within the state/locale. 3. Pr ovide input to EP A-developed CHP Partnership tools and services, including state/locale-specific data and analysis. 4. Employ CHP Partnership tools and services, as appr opr iate, to r ecognize and pr omote CHP development within the state/locale. 

## EP A W ill: 1. Support the State/Local Partner with tools and services including state/locale-specific data and analysis. 2. Support the State/Local workshop thr ough logistics and planning. 

### Please fax the completed Letter of Intent (2 p ages) to 617/482-1320 (contractor in support of EP A)

3. Designate a Pr ogram Manager as Partner liaison. 

## General T e r ms: 1. This agr eement can be terminated by either party, at any time, without pr ior notification, penalties or further obligation. 2. The State/Local Partner agr ees that the activities it undertakes associated with this voluntary agreement ar e not intended to pr ovide services to the federal gover nment and that the Partner will not seek compensation fr om a federal agency. 3. The State/Local Partner agr ees that it will not claim or imply that its participation in the Partnership constitute EP A appr oval or endorsement of anything other than its commitment to the Partnership. 

### Please complete the information on page 2.________________________________________________________________________________________________

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 

## State Par tner's Liaison: Name: __________________________________________________________________________________________ Title: ____________________________________________________________________________________________ State/Local Agency: ________________________________________________________________________________ Addr ess: _________________________________________________________________________________________ City: _________________________________________________________ State:_______ Zip: __________________ T

elephone: __________________________________________ Fax: ________________________________________ E-mail: __________________________________________________________________________________________ 

## Additional Par tner Infor mation: Y

our agency’ s W eb site addr ess: _____________________________________________________________________ Does your agency have a CHP-r elated W eb page? If so, please list her e: May we pr ovide a link to your CHP-r elated W eb page? Ye s No Please pr ovide a br ief pr ofile of your agency’ s involvement in CHP . (If the space below is not adequate, please mail or fax this information to us on separate pages, along with your signed Letter of Intent.):

The gover nment estimates the average time needed to fill out this form is 4.9 hours and welcomes suggestions for reducing this level of ef fort. Send comments (r efer encing OMB contr ol number) to the Dir ector , Collection Strategies Division, U.S. EP A (2822T), 1200 Pennsylvania A ve., NW , Washington, D.C. 20460. PLEASE F AX THE COMPLETED LETTER OF INTENT T O 617/482-1320 (contractor in support of EP A) Of

fice of Air and Radiation EP A-430-F-05-035 (6202J) www .epa.gov/chp October 2005 Page 2