Form 6500-03 Annual Reporting Form

STATE SMALL BUSINESS STATIONARY SOURCE

TECHNICAL AND ENVIRONMENTAL COMPLIANCE

ASSISTANCE PROGRAM (SBTCP)

ANNUAL REPORTING FORM

FOR THE PERIOD 1/01 TO 12/31 (Each Calendar Year)

OMB CONTROL NO.: 2060-0337

EXPIRATION DATE: ___/___/___

*** Completed forms are due by March 31 of each year ***

This is the Annual Reporting Form for the State Small Business Stationary Source Technical and Environmental Compliance Assistance Programs (SBEAPs) under the Clean Air Act (CAA) as amended in 1990. We are collecting objective information on each SBEAP. This report is not an evaluation of your program.

INSTRUCTIONS FOR COMPLETING THIS FORM

1. STOP! Save (using the save function from the File menu) this document to your hard drive using the name of your State or Territory as the document title before continuing.

2. Please complete the electronic version of the Form. Do not answer questions by referring to attached documents or a previous SBTCP report.

3. You should have already collected the requested information. If a question asks for data you do not have, please briefly explain in the narrative section of this document why it is not available. For future reports, you may need to revise the statistics that you track.

4. Each answer block (with the noted exceptions) must be answered completely. If part of the question does not apply, indicate "not applicable", "N/A", “0”, or another appropriate answer.

5. In the narrative section at the end of the Form you may cut and paste text from another file, however you will not be able to spell check the text after pasting. It is recommended that you check spelling and grammar prior to pasting into this document.

6. Once your form is complete please file a copy for future reference and e-mail a copy of the document to Angela Suber at [email protected].

7. See the “Definitions” on the following page to assist you in what to count in your report.

8. Contact Angela Suber at 202 566-2827 if you have any questions, or e-mail [email protected].

SUGGESTIONS FOR COMPLETING THIS FORM

• Gathering information for this report is definitely a team effort! Enlist the help of key contacts from the SBO, the SBEAP, and the CAP, and ask them to complete applicable sections.

• Assign responsibility to one person for completing and submitting this Form (most likely the SBO).

• Refer to last year's 507 Program Report and the information you provided on your Reporting Form when completing this year's Reporting Form.

Definitions: The following definitions are a guide for gathering information for the Annual Report they are not all-inclusive, however should be used to determine how to count total assistance and total outreach activities.

1) On Site Visit: a one-on-one meeting at the business work site to answer questions about environmental issues, to assist with self audit activities, or present information about environmental programs. Not an inspection. Each time a site visit is made to the same site, it counts as an additional visit for total assistance provided. Note: if the site visit turns into a permit assistance visit, you may count as a site visit and a permit assist.

2) Phone calls Made/Received: phone calls made to business, trade associations, federal offices, or the general public that answer questions about environmental issues, or are in the course of researching an environmental question. Phone calls received, either “hotline” or standard office phone that relate to assistance in understanding environmental regulations or questions about environmental issues combined with phone calls made will give you the total number.

3) E-Mails Received/Made: e-mail activities in relationship to compliance assistance.

4) Workshops/Seminars: the number of total workshops and seminars that were attended or provided to anyone for any reason by SBO/SBEAP Staff in the State. Include a count of all attendees.

5) Permit Assistance: any type of assistance provided to a business in relationship to permit or compliance requirements, reviews, written permits, answering questions about permits, or directing business owner or managers to the correct office or web site for additional assistance.

6) Walk-ins: any visit to the SBO/SBEAP’s office for meetings or one-on-one assistance.

7) Publication/direct mail/newsletters (Compliance Assistance Tools): number of publications that were mailed directly to a business or the general public. The total number for assists will equal the total distribution of documents. Not total published documents.

8) Other types of Assistance and Activities: events like Public Service Announcements, Radio Talk Shows, news print, special events, state fairs, presentations for the public, speaking engagements that can not be defined as to total number of businesses reached, may be counted. This is an estimated audience reached as part of the total effort of your office. Estimated numbers should be as accurate as possible.

9) Computer Web-sites Hits: Hits are contacts made by outside organizations or the general public to obtain information about your environmental assistance program, regulations, or guidance through access to your web site.

PROGRAM INFORMATION

Provide the name of the State or Territory for which this report is being submitted.

	REPORTING FORM CONTACT
Name
Title
Agency/Organization
Address
City, State, Zip
Telephone Number	( ) - X
FAX Number	( ) -
E-mail address

BUDGET

Record the combined budget for your SBO, SBEAP, and CAP for calendar year. (If your budget is by fiscal year, please indicate the FY budget that is in effect as of 12/31)

2008 Budget Total	$
Sources	□Title V Fees	□105 Funds	□Other
Budget Change	□ Increase	□ Decrease	□ No Change

STAFFING

How many employees, measured as full-time equivalents (FTEs), support the SBO/SBEAP?

Total FTEs
SBO Staff #	SBEAP Staff #

What is status of your Compliance Advisory Panel (CAP)?

Status	Check if applicable
Do you have a CAP?	□ Yes □ No # Positions Vacant
Active (holding meetings or conference calls)	□ Yes □ No □ N/A

OUTREACH AND TECHNICAL ASSISTANCE

Does your program offer air-only or multimedia assistance?

□ Air only

□ Multimedia

Please provide the requested data for each type of activity during the year.

Method of Assistance Provided	# of Events	Total Assists
1) Site Visits
2) Phone calls Made and Received
3) E-mails Made and Received
4) Permit Assistance
5) Walk-ins
6)Mailings/Newsletters/Publications Distributed to a Business or Public
7) Workshops and Seminars
Total Assistance Provided

Please provide information on Outreach Activities for the calendar year.

Other Types of Assistance Provided	# of Events	Estimated Audience
8) Public Service Announcements
9) Radio Talk Shows
10) Other Special Events
11)
12)
13)
14)
Total Outreach

Web Site Activity: How many times did people access your web site to get information on your environmental assistance program?

Your Web Site Address	Number of Web Site Pages	Total Number of Hits

Please include information about your program that you would like to highlight, such as significant accomplishments, awards, actions taken to move to multimedia, changes in annual budget or FTE’s, etc. Positive outcomes and case studies are especially appreciated!

Burden Statement

The public reporting and recordkeeping burden for this collection of information is estimated to average 40 hours 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.

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EPA Form Number 6500-03