Form 5900-16 ENERGY STAR - Statement of Energy Performance

OMB No. 2060-0347

STATEMENT OF ENERGY PERFORMANCE
Sample Facility
Building ID: 123456
For 12-month Period Ending: October 31, 20051
Date SEP becomes ineligible: February 28, 2006

Facility Being Labeled
Sample Facility
1234 Main Street
Springfield, VA, 10000

Facility Owner
Sample Owner
4567 Peach Ave.
Springfield, VA 10000
555-555-5555

Date SEP Generated: November 10, 2005

Primary Contact for this Facility
Jane Smith
7890 Columbia Way
Springfield, VA 10000
555-555-5566
[email protected]

Year Built: 1999
Gross Building Area (ft2): 20,000
Energy Performance Rating 2 (1-100): 80
Facility Space Use Summary
Space Type
Area (ft2)
Garage
5,000
Office (General)
15,000

Occupants
2
40

Site Energy Use Summary
Electricity (kBtu)
Natural Gas (kBtu)3
Total Energy (kBtu)

123,456
123,456
246,912

Energy Intensity 4
Site (kBtu/ft2-yr)
Source (kBtu/ft2-yr)

6.3
19.5

Emissions (based on site energy use)
CO2 (1000lbs/yr)
263

Operating Hours
40
40

Number of PCs
0
40

Professional Engineer Stamp
I certify that the information contained within this
statement is accurate and in accordance with the
PE Guidelines.

Indoor Environment Criteria 5
Indoor air pollutants controlled?
Adequate ventilation provided?
Thermal conditions met?
Adequate illumination provided?

Yes
Yes
Yes
Yes

Professional Engineer
License Number: 0000001
State: VA
John Doe
1234 Vineyard Lane
Springfield, VA 10000
555-555-7788

Notes:
1. Application for the ENERGY STAR must be submitted to EPA within 4 months of the Period Ending date. Award of the ENERGY
STAR is not final until approval is received from EPA.
2. The EPA Energy Performance Rating is based on total source energy. A rating of 75 is the minimum to be eligible for the
ENERGY STAR.
3. Natural Gas values in units of volume (e.g. cubic feet) are converted to kBtu with adjustments made for
elevation based on Facility zip code.
4. Values represent energy intensity, annualized to a 365 day calendar.
5. Based on meeting ASHRAE Standard 62-1999 for indoor air quality, ASHRAE Standard 55-1992 for
thermal comfort, and IESNA Lighting Handbook for lighting quality.

Tracking Number: SEP20060101000001234
The government estimates the average time needed to fill out this form is 6 hours (includes the time for entering energy data, PE facility inspection,
and notarizing the SEP) and welcomes suggestions for reducing this level of effort. Send comments (referencing OMB control number) to the Director,
Collection Strategies Division, U.S., EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
EPA Form: 5900-16