5900-89 Statement of Energy Performance - Plants

					OMB Control No. 2060-0347
		STATEMENT OF ENERGY PERFORMANCE
		Enter Name
		For 12-month period ending:			Enter Month/Day/Year
	Facility Address		Owner's Address		Corporate Energy Manager Contact
	Enter Name		Owner's Name		Contact Name
	Street Address		Street Address		Email Address
	Address 2		Address 2		Phone Number
	New York, NY		City, State
	10000		ZIP
	Automobile Assembly Plant Energy Performance Indicator
	Energy Performance Score:		100
	GHG Savings (Kg CO2e)		165
	Energy Savings (MMBtu)		3
	Professional Verification
	Professional Engineer Name
	Address
	Address 2
	City, State ZIP
	Phone Number:
	License Number:
	Licensing State:				Professional Engineer Stamp
	EPI Verification				Based on the conditions observed at the time of my visit to this facility, I certify that the information used in this tool to generate the energy performance score represented on this statement is accurate.
	NOTE:
	1. Applications for certification of plant energy performance to the US EPA must be made within 4 months of Period Ending date. Award of the ENERGY STAR is not final until approved by the US EPA.
	2. All energy performance scores and supporting data must first be verified by the US EPA or a US EPA-designated EPI reviewer if supporting data is considered to be proprietary before submitting applications for the ENERGY STAR.
	3. An energy performance score of 75 is the minimum required score to be considered eligible for the ENERGY STAR.
	4. Estimates of energy and CO2 emissions savings are provided to illustrate the difference between the benchmarked plant's energy use and estimated CO2 emissions as compared to "an average plant" that is defined as having an energy performance score at the 50th percentile. The fuel mix used to estimate emissions data for the average plant is the same as for the benchmarked plant. These estimates are provided to assist plants with communicating their energy and environmental achievements.
	For US EPA Use Only:

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 5900-89