Form 5900-19 Attachment to C&I Partnership Letter

OMB Control No. 2060-0347

Attachment to Partnership Letter

Organization Information

Chief Executive Energy Manager

Name & Title: _______________________ Name & Title: _______________________

Mailing Address: _______________________ Mailing Address: _______________________

_______________________ _______________________

_______________________ _______________________

E-mail Address: _______________________ E-mail Address: _______________________

Phone Number: _______________________ Phone Number: _______________________

Facsimile: _______________________ Facsimile: _______________________

Communications Contact

Name & Title: _______________________

Mailing Address: _______________________

_______________________

_______________________

E-mail Address: _______________________

Phone Number: _______________________

Facsimile: _______________________

Organization’s Primary Business or Function (check one):

□ Commercial Real Estate

□ Corporate Real Estate

□ Multifamily Housing, include:

_____ Number of units owned/managed

□ K-12 Education

□ Higher Education

□ State Government

□ Local Government

□ Federal Government

□ Healthcare & Senior Care Facilities

□ Hospitality & Entertainment

□ Manufacturing/Industrial, include:

_____ NAICS code

_____ Number of Manufacturing Plants Operated in the United States

_____ Number of Employees in the United States

□ Religious (Congregations)

□ Retail

□ Drinking Water Treatment and Distribution, include:

_____ Total Capacity (mgd)

□ Wastewater Treatment, include:

_____ Total Capacity (mgd)

□ Other. Describe: _____________________________________

Organization’s total building/facility square footage (required):

Owns _____________________________________

Leases _____________________________________

Manages _____________________________________

How did you learn about Energy Star?

_____________________________________________________________________________________

_____________________________________________________________________________________

The public reporting burden for this collection of information is estimated to average 30 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 (28221T), 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 5900-19