5900-387 PE Verification Form

OMB Control No. 2060-0347

Appendix 6: PE Verification Checklist
Site name and address:_________________________________________________________
____________________________________________________________________________
Date: ________________
Name of PE completing this form:________________________________________________
Review location: Corporate Office ___ Site Visit ___
Site Physical Characteristics and Eligibility
The site has established a formal site file. Yes___ No___
Location of the formal site file:_____________________________________________________
The site meets the definition of an industrial site defined in the site requirements. Yes___ No___
The site’s physical characteristics and any other site-specific information required on the Statement of
Energy Improvement (e.g., site name, location, parent company information, and contact names)
match that of the site applying for the ENERGY STAR Challenge for Industry recognition. Yes___
No___

Site Operating Characteristics
The site’s registered baseline and energy intensity metric were approved by U.S. EPA. Yes___
No___
The data used to track the energy performance of the site is from the site named on the Statement of
Energy Improvement. Yes___ No___
All information supporting the non-energy operating characteristics used to calculate the site’s energy
intensity metric is documented. Yes___ No___
An Energy Tracking Plan or existing data management procedures were in place during the duration
of the site’s participation in the ENERGY STAR Challenge for Industry. Yes___ No___
All data was tracked consistently throughout the duration of participating in the ENERGY STAR
Challenge for Industry. Yes___ No___
For production-based energy metrics, the production units used for calculating the energy intensity
metric are consistent with the numbers from the official company production records. Yes___ No___
For building-based energy metrics, the gross square footage of the site used for calculating the
energy intensity metric are consistent with company records. Yes___ No___
For complex energy metrics, the approach was applied consistently during the tracking period and the
data used matches the origin of the original normalized/multivariate data used to develop the metrics.
Yes___ No___
The production, gross square footage and/or normalized data used to calculate the energy intensity
match the data found in the site’s energy tracking system. Yes___ No___
All data used reflects the whole facility and not a single process or individual part of the site. Yes___
No___

Site Energy Consumption

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EPA Form No. 5900-387

All energy consumption for each energy source used to operate the facility and manufacturing
processes (including purchased and generated) was accounted for and reported in the Statement of
Energy Improvement. Yes___ No___
All information supporting the energy consumption used to calculate the site’s energy intensity metric
is documented. Yes___ No___
All information supporting the energy consumption used to calculate the site’s energy intensity metric
is treated consistently across the baseline and tracking periods, especially for energy sources that
may be invoiced at irregular (non-monthly) intervals. Yes___ No___
If site exports electricity or steam, these exports have been subtracted from the site’s total energy
use. Yes___ No___ N/A, site does not export._____
All forms of energy purchased and used on site were properly converted to BTUs, summed and
reported on the Statement of Energy Improvement as site energy. Yes___ No___
All energy was properly converted from “site” to “source” energy, summed and reported on the
Statement of Energy Improvement as source energy. Yes___ No___
All data used reflects the whole facility and not a single process or individual part of the site. Yes___
No___

Site Energy Intensity Improvement
The baseline data entered into the Statement of Energy Improvement matches the baseline approved
by U.S. EPA when the site registered to participate in the ENERGY STAR Challenge for Industry.
Yes___ No___
If no, an explanation for the difference must be noted in this checklist (below), accompanied by any
necessary supporting documentation.
The site reduced its energy intensity by at least 10 percent within 5 years of the conclusion of the
baseline period, and all data was accurately recorded in the Statement of Energy Improvement.
Yes___ No___
The period during which the energy intensity reduction was achieved ends no earlier than 12 months,
nor later than 60 months, from the conclusion of the baseline period. The 10 percent energy intensity
reduction is calculated against the baseline period for the final 12 months of the tracking period.
Yes___ No___
The tracking period begins immediately following the end of the baseline period and continues
through the end of the period for which the 10 percent reduction is achieved. Yes___ No___

Site Annual Carbon Dioxide Emissions Avoided (Optional)
If site has reported the avoided carbon dioxide equivalent (CO2e), the emission estimates that are
linked with the energy intensity reduction were calculated correctly using proper emission factors.
Yes___ No___ N/A, site has not reported CO2e.____

Completion of Formal Site File
All documentation/calculations supporting all the statements above are located in the formal site file.
Yes___ No___

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EPA Form No. 5900-387

PE Verification
The PE completed the PE Verification Checklist for submission to U.S. EPA, and added the original
document to the formal site file. Yes___ No___
The PE validated the Statement of Energy Improvement (includes: signing, stamping – indicating if
embossed, and providing the required license information) for submission to U.S. EPA, and added
the original document to the formal site file. Yes___ No___

Please note any company personnel involved in
review:______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Please note any findings, corrections, or recommendations from the review:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

The public reporting and recordkeeping burden for this collection of information is estimated to average 25 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 No. 5900-387

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