Form 6200-01 NPEP Enrollment Form

ENROLL US

We Want to Be a Partner in EPA’s

National Partnership for Environmental

Priorities

PARTNER AGREEMENT

Our organization is choosing to become a partner in EPA's National Partnership for Environmental Priorities. Our goal is to reduce the quantity of one or more Priority Chemicals currently found in our products, processes, or releases using techniques such as source reduction, recycling, or other materials management practices. In this enrollment application, we identify one or more voluntary goals that we believe we can achieve as partners in this program. The voluntary goal(s) provided below is an initial estimate and may change over time. We may revise our goal(s) or withdraw from the program at any time. If/when we choose to revise our goals or withdraw from the program, we will notify EPA.

DEFINITIONS

“Source Reduction” is altering the design, manufacture, or use of products and materials to eliminate or reduce the use or release of hazardous chemicals.

“Recycling” is sorting, collecting, and processing materials to manufacture and sell them as new products.

“Material Management” is minimizing the amount of materials involved in processes as well as their associated environmental impacts by using/reusing resources throughout their life cycles.

IDENTIFYING INFORMATION

Organization Name:_________________________

Facility Name:_____________________________

Address: _________________________________ City/State/Zip: ____________________________

Industrial Sector: __________________________

Parent Company: __________________________

Principal Contact: __________________________

Title: ____________________________________

Phone: __________________________________

Email: ___________________________________

Authorizing Official: ________________________ Title: ____________________________________

NAICS Code or Sector: _____________________

Date: _______________

How did you find out about our program:

_________________________________________

Goal #1:

(Please see the back for examples)

Is this goal Source Reduction, Recycling, or Materials Management (please check appropriate box)?

SR ____­­­____

R _________

MM_______

Name of Targeted Chemical or CASRN: _________________________________________

DESCRIPTION OF PROPOSED PROJECT

(Please see the back for examples)

(Please include general process change descriptions):

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

How We Will Measure Success

Our goal is to change the amount of the targeted chemical used/released/recycled from a baseline amount of _______ pounds in ________ (month/year)

to a reduced amount of _______ pounds generated/used/recycled by _______________ (month/year).

Quality Assurance/Control

We have a Quality Assurance/Quality Control Plan for data (Please check which applies). Yes __ No __

Benefits of Joining NPEP

Public recognition for achieving voluntary chemical management improvements.

Information about your organization and your goals posted on our Partners Page.

Your environmental achievements and Success Stories posted on the NPEP website.

Use of EPA's NPEP logo to identify your organization as a partner (please note that EPA cannot endorse the purchase of a particular company's products or services).

The opportunity to display your NPEP membership plaques and achievement awards to customers, suppliers, employees, and stockholders.

At your request, EPA will notify your local media of your program accomplishments.

Technical Assistance from our State and Regional NPEP staff.

The opportunity to network with other NPEP partners and members of the materials management community.

How to fill out the “Goal” Section

1. Review how your project relates to the “Definitions” section and check;

   1. SR for Source Reduction,

   2. R for Recycling, or

   3. MM for Materials Management.

2. If your project will reduce one of our priority chemicals, list the targeted chemical(s) and that chemical’s related CASRN (Chemical Abstracts Service Number).

3. Briefly describe you project, referencing whether you will use any or all of the following

   1. Equipment of Technology change,

   2. Redesign of Product,

   3. Improved Inventory Control,

   4. Process Modification,

   5. Material Substitution, or

   6. Other.

4. For your targeted chemical provide

   1. The number of pounds you will reduce the use of or recycle, and

   2. Project Beginning and Ending Dates.

5. Check whether you have a Quality Assurance/Quality Control Plan for data.

Yes: ­­­________ No: _________

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