5900-265 EPI Award Specification Sheet

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