Document ID: EPA-HQ-OAR-2006-0407-0057
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2016-02-12T05:00Z

OMB Control No. 2060-0347

Date

	Plant name as it will appear on Certificate

	Company name as it will appear on Certificate

	

Corporate energy manager contact information

Name

	Title

	Organization

	Address 1

Address 2

	City

	State

	Zip code

	Email

	Phone

	

Organization/Plant Owner’s Chief Executive Officer information:

Name

	Title

	Organization

	Address 1

Address 2

	City

	State

	Zip code

	Email

	Phone

	

Professional Engineer information

Name

	Title

	Organization

	Address 1

Address 2

	City

	State

	Zip code

	Email

	Phone

	License number

	

Plant Owner information:

Company or Parent Company Name

	Address 1

Address 2

	City

	State

	Zip code

	Web address:

	Phone

	

NOTE:  Unless specified otherwise, all recognition materials (the bronze
plaque, the banner/flag graphic, and the letter of congratulations) will
be addressed to and sent to the Corporate Energy Manager at the location
specified above.  The letter of congratulations for the CEO will be sent
directly to the address provided for the CEO.

Please specify any other information/requests for distribution of
recognition materials in the space below.

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