Form DOE HQ F 413.37 DOE HQ F 413.37 SEP Application

DOE HQ F 413.37

(03/18)

(Replaces DOE HQ F 413 and DOE HQ F 413.1,

All other edition is obsolete)

50001 Superior Energy Performance® 2018
Application for Certification

Version 3.0: 02-28-2018

Contents

Introduction 1

Application 2

Section 1: Overview 2

Section 2: Facility Information 3

Section 3: Optional for Each Facility 7

OMB Burden Disclosure Statement and Confidentiality 9

Introduction

50001 Superior Energy Performance® (50001 SEP®) is program that recognizes excellence in energy management systems (EnMS) by certification of a facility’s implementation of the ISO 50001 Energy management system-Requirements with guidance for use standard (ISO 50001) EnMS and additional SEP requirements. Organizations that achieve ISO 50001 and 50001 SEP Certification receive certificates from third-party certification bodies indicating ISO 50001 and 50001 SEP requirements have been achieved, under the ANAB-accredited ISO 50001 and 50001 SEP designations. Additional recognition from the SEP Program Administrator¹ is available for those organizations that use the 50001 SEP Scorecard.

Note 1: Within the United States, the 50001 SEP Program Administrator is the US Department of Energy (US DOE). The US DOE describes its recognition of 50001 SEP facilities within the document titled “US Department of Energy 50001 SEP Recognition and Awards.” Recognition includes 50001 SEP, 50001 SEP Silver, 50001 SEP Gold, and 50001 SEP Platinum levels. In the future, other national government (energy and/or environmental) agencies may create separate but similar recognition and award programs specific to their country.

Apply

A facility will submit a certification application to the 50001 SEP Program Administrator once the EnMS has been implemented, the energy performance improvement has been achieved, and the facility is prepared for the verification audit. In this application form, applicants will provide information such as contact information, facility information, models, and any alternative approaches used. This information helps the 50001 SEP Program Administrator understand the basic approaches the facility has used and whether the applicant is requesting approvals for any alternative approaches.

Once the 50001 SEP Program Administrator reviews and approves the application, applicants will be notified, after which, the 50001 SEP Program Administrator will provide the application package to the 50001 SEP Verification Body selected by the applicant. Please submit completed application or questions to the 50001 SEP Program Administrator via email: [email protected].

If you wish to use any of the alternative approaches listed on the 50001 SEP Approvals page [http://energy.gov/eere/amo/pre-approvals-needed-alternative-approaches], we strongly encourage you to submit any request form(s) to the 50001 SEP Program Administrator prior to submitting the application, so the alternative approaches can be approved prior to submission of the application to the 50001 SEP Verification Body. If you request approval for alternate approaches at the same time as you submit the application, the application process could be delayed.

Application

Please submit the application to the 50001 SEP Program Administrator: [email protected].

Section 1: Overview

Type of Application

1. Please select the type of certification application below

☐ Central Office Application

(This option is for organizations that are submitting an application for multiple facilities to become 50001 SEP certified under a central office. If this option is checked, please fill out Section 2 for each facility.)

1. Central office location: Click here to enter text.

   • Is this a virtual location? ☐Yes ☐No

2. Total Number of Facilities Applying for 50001 SEP: Click here to enter text.

3. Are these facilities being added to an existing ISO 50001 certificate?

☐Yes ☐No

☐ Close Geographic Proximity Site Application

(This option is for organizations that are submitting an application for multiple sites within close geographic proximity that will apply as one facility for 50001 SEP, see MSE 50021:2018, Annex A.1.1 for more details.)

1. Number of sites under this facility: Click here to enter text.

2. Number of utility electric and gas revenue meters under this facility: Click here to enter text.

3. Distance between sites: Click here to enter text.

4. Typical mode of transportation between sites (e.g., walking, golf cart, car):

Click here to enter text.

5. Is there a unique energy type at any of these sites? Please describe. Click here to enter text.

☐ Individual Facility Application

Main Organizational Contact Information

2. Please enter the information for the organization’s main contact below.

1. Organization Name: Click here to enter text.

2. Parent Company Name (if applicable): Click here to enter text.

3. Organization Contact Name: Click here to enter text.

4. Contact Title: Click here to enter text.

5. Main Contact Address: Click here to enter text.

6. City, State, Zip Code: Click here to enter text.

7. Phone Number: Click here to enter text.

8. Email Address: Click here to enter text.

Section 2: Facility Information

Facility Statement

3. Click here to enter text. (name of facility and location) seeks to complete a:

☐ 50001 SEP certification audit

☐ 50001 SEP recertification audit (Note: for the application to qualify as recertification, it must be submitted at least 6 months before the certificate expiration date.)

1. For recertification, please answer the following questions.

   1. When was this facility’s initial 50001 SEP certification date? Click here to enter a date.

   2. What was this facility’s last certification baseline period (MM/YY - MM/YY)? Click here to enter text.

   3. Are there changes to the certification scope for this facility?

(Note: This will require a Stage 1 audit for recertification)

☐Yes ☐No

Facility Contact Information

4. Facility Contact Information*

1. Facility Name: Click here to enter text.

2. Street Address: Click here to enter text.

3. Mailing Address: (if different than street address) Click here to enter text.

4. City, State, Zip Code: Click here to enter text.

5. Country: Click here to enter text.

6. Is the facility contact the same organizational contact listed in question 2?

☐Yes ☐No

If Yes, skip to next question. If No, fill in g-j.

7. Contact Name: Click here to enter text.

8. Contact Title: Click here to enter text.

9. Phone Number: Click here to enter text.

10. Email Address: Click here to enter text.

*If “Close Geographic Proximity Site Application” was selected in question 1, please copy and paste 4a-4e and provide the information for each site included in the facility boundaries before the next question.

Basic Facility Information

5. Facility Information

   1. NAICS Code(s): Click here to enter text.

   2. Square footage: Click here to enter text.

   3. Number of employees: Click here to enter text.

   4. Number of EnMS effective personnel:¹ Click here to enter text.

   5. Number of shifts: Click here to enter text.

   6. Information such as products or services produced as applicable: Click here to enter text.

6. Scope and Audit

   1. Scope for 50001 SEP and ISO 50001 certification (and please note if the scope for SEP is different than ISO 50001):

Click here to enter text.

2. Scope exclusions: Click here to enter text.

3. Any restrictions that may limit audits within the proposed scope:

Click here to enter text.

4. Is this facility currently certified to ISO 50001?

☐Yes (answer i-iii below) ☐No (continue to part e)

1. Please provide the scope (or note “same as 6a”):

Click here to enter text.

2. Certification Body for current ISO 50001 certification: Click here to enter text.

3. For your 50001 SEP certification, will you be recertifying to ISO 50001 at the same time?

☐Yes ☐No

5. Have you selected a 50001 SEP Verification Body?²

☐Yes (answer i-ii below) ☐No (Skip to next question. Please select a 50001 SEP Verification Body and notify the 50001 SEP Program Administrator as soon as possible.)

1. Please provide:

50001 SEP Verification Body name: Click here to enter text.

If you work with a specific individual at the 50001 SEP Verification Body, please provide that person’s name, email, and phone: Click here to enter text.

2. If this is a 50001 SEP recertification audit, are you keeping the same 50001 SEP Verification Body?

☐Yes ☐No ☐N/A

Facility Energy Information

7. Energy types and significant energy uses:

   1. Number of and type energy types: Click here to enter text.

   2. Number of significant energy uses (SEUs): Click here to enter text.

8. Please check the appropriate category that indicates this facility’s total annual site energy consumption during the reporting period³

Facility Annual Site Energy Consumption Table 1* (per ISO 50003:2014)

< 189,563 MMBTU/Year (200 Terajoules/Year)	☐
189,563 to 1,895,626 MMBTU/Year (200 to 2,000 Terajoules/Year)	☐
1,895,627 to 9,478,133 MMBTU/Year (2,000 to 10,000 Terajoules/Year)	☐
> 9,478,133 MMBTU/Year (10,000 Terajoules/Year)	☐
* Conversion factor: 1 MMBTU = 0.00105506 Terajoules

9. Time Periods and Energy Performance Improvement

   1. Baseline Period (MM/YY – MM/YY): Click here to enter text.

   2. Reporting Period (MM/YY – MM/YY): Click here to enter text.

   3. Achievement Period: ☐ 1 year ☐ 2 years ☐ 3 years

   4. ☐ Estimated energy performance improvement for the achievement period (rounded to nearest tenth): Click here to enter text.%

Note: This is to provide an idea of the range of energy performance improvement and the facility is not committing to this % improvement. The final energy performance improvement achieved and verified by the 50001 SEP Verification Body will be published on the 50001 SEP web site if the facility chooses.

10. Adjustment Model

This question refers to the 50001 SEP Energy Performance Indicator (SEnPI), which is defined in the 50001 SEP Measurement and Verification Protocol. In determining the SEnPI, select the method that the facility used: (Please select one.)

☐ Linear regression model

☐ Forecast

☐ Backcast

☐ Standard conditions

☐ SEnPI chaining

☐ Ratio of energy consumption to single production level

Note: Use of the “ratio of energy consumption to single production level” requires the ability to meaningfully represent all output in a single quantity, such as total tons or gallons per year. However, in most cases, the consumption depends on more than one production quantity and may also depend on additional factors including weather and non-production related energy consumption. In these cases, this approach would not be appropriate. Evidence must be provided to support the claim of only one relevant variable and that the ratio form is adequately predictive of energy performance.

☐ Complex regression model

☐ Polynomial model

☐ General nonlinear model

☐ Other model (Note: all other model options require review and approval by the 50001 SEP Program Administrator in advance of the Stage 1 audit. See the Measurement and Verification Protocol for more details.)

Note: Any rationale for using a complex regression model that differs from those listed in the 50001 SEP Measurement and Verification Protocol must be submitted to the 50001 SEP Program Administrator for approval prior to or with the application. [See question 11]

Alternative Approaches

If alternative approaches that require approval from the 50001 SEP Program Administrator are being used, please answer this question. All alternative approaches must be approved by the 50001 SEP Program Administrator. For more information on alternative approaches and to download forms, visit: [http://energy.gov/eere/amo/pre-approvals-needed-alternative-approaches]. Send the completed Request for Approval Form(s) to the 50001 SEP Program Administrator ([email protected]).

11. Request to use alternative approach (Please select all that apply.)

☐ The methodology and calculation for derived energy types proposed not listed in the 50001 SEP M&V Protocol. [See Request for Approval Form 2]

For 50001 SEP Program Administrator only: Approved on Click here to enter a date.

☐ Justification of non-routine adjustments, including calculations. [See Request for Approval Form 6]

For 50001 SEP Program Administrator only: Approved on Click here to enter a date.

☐ Justification of other deviations not addressed explicitly in the 50001 SEP M&V Protocol, including calculations. [See Request for Approval Form 7]

For 50001 SEP Program Administrator only: Approved on Click here to enter a date.

☐ Any other alternative approaches or situations that require review and approval by the 50001 SEP Program Administrator. [See Form TBD]

Note: Applicants are strongly encouraged to submit their Request for Approval Form(s) prior to submitting the application to avoid delays in the application process; however these forms are also accepted when the application is submitted.

Application Submission

Individual submitting this application: ☐Main Organizational Contact ☐Facility Contact ☐Other

Name: Click here to enter text.

Title: Click here to enter text.

Address: Click here to enter text.

Phone Number: Click here to enter text.

Email Address: Click here to enter text.

Date: Click here to enter a date.

Individual authorizing this application: ☐Main Organizational Contact ☐Facility Contact ☐Other

Name: Click here to enter text.

Title: Click here to enter text.

Address: Click here to enter text.

Phone Number: Click here to enter text.

Email Address: Click here to enter text.

Date: Click here to enter a date.

Section 3: Optional for Each Facility

12. Does this facility have experience with other ISO management systems?

    1. ☐Yes (complete b) ☐No (skip to next question)

    2. Which ISO management systems? (Please select all that apply.)

☐ISO 9001 ☐ISO 14001 ☐Other: Click here to enter text.

13. What is this facility’s estimated total annual energy bill?

Annual Total Energy Bill
☐	< $500,000/Yr
☐	$500,000 to $1,000,000/Yr
☐	$1,000,001 to $2,000,000/Yr
☐	$2,000,001 to $5,000,000/Yr
☐	> $5,000,000/Yr
☐	Not sure

14. Does this facility have a dedicated energy manager⁴?

☐Yes ☐No

15. Have you used any of the following energy management resources in your energy management program implementation? (Please select all that apply.)

☐ DOE AMO Energy Resource Center (e.g., Energy Performance Indicator Tool, 50001 Ready Navigator)

☐ENERGY STAR energy management guidelines and tools

☐Electric or gas utility strategic energy management technical assistance or rebates

☐External energy consultant

☐ Energy equipment supplier or service provider

☐ Other: Click here to enter text.

16. What factors motivate your organization’s decision to pursue 50001 SEP? (Please select all that apply.)

☐Energy cost reduction

☐Customer demand for energy and sustainability practices

☐Corporate reputation

☐Greenhouse gas emission reduction

☐External validation of energy saving

☐Other: Click here to enter text.

17. Name of this facility’s gas utility: Click here to enter text.

18. Name of this facility’s electric utility: Click here to enter text.

19. We will provide you with periodic informational emails. To add members of this facility’s energy management team on these emails, please list their names, email addresses, and roles below.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

For a Central Office Application, please include any other facility applications below this point.

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<END OF APPLICATION FORM>

OMB Burden Disclosure Statement and Confidentiality

OMB Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 1 hour per response for the 50001 SEP Application Form, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records & Privacy Management Division, IM-23, Paperwork Reduction Project OMB Control #: 1910-5177, U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project OMB Control #: 1910-5177, Washington, DC 20503.

Confidentiality

The U.S. Department of Energy (DOE), as the 50001 SEP Program Administrator within the United States, maintains the confidentiality of proprietary energy and production related data as proprietary that is submitted to the 50001 SEP program by 50001 SEP certified facilities, to the fullest extent of U.S. federal law. Data included within the 50001 SEP Application Forms, 50001 SEP Energy Performance Improvement Report, 50001 SEP Voluntary Cost Benefit Form, and any other forms or data shared with the U.S. DOE will not be released publicly. The U.S. DOE will publicly report the following information about each 50001 SEP certified facility:

1. Facility name

2. Facility location (city, state)

3. Verified achievement period energy performance improvement

   1. The 50001 SEP certified facility can elect if energy performance improvement is reported, or not. If the energy performance improvement is reported, the facility has the option to report as an absolute value of energy savings (British thermal units (BTU)), a percentage value as compared to the energy baseline (SEnPI), or both.

4. Verified achievement period length

5. Certification date (month/year)

US DOE will, from time-to-time, publicly share aggregate, program-wide metrics, such as the number of 50001 SEP certified facilities, and annual and cumulative 50001 SEP program energy savings without revealing data or analysis that could lead to the identification of specific facilities.

US DOE may use data to study the effectiveness and impact of the 50001 SEP program. Results from such analysis will be made public only if participating organization anonymity can be ensured. The participating organization may be asked if they wish to voluntarily participate in the formation of case studies and other activities regarding the 50001 SEP program.

All data provided to US DOE is subject to the Freedom of Information Act (FOIA); however, US DOE will notify the 50001 SEP certified facility if a FOIA request has been submitted for which their data might be responsive. US DOE will consult with the 50001 SEP certified facility and ensure the facility has an opportunity to inform US DOE what data they view is proprietary. US DOE will review the 50001 SEP certified facility’s suggestions and will not release to the public any data US DOE deems proprietary.

Individual 50001 SEP Verification Bodies have established and implemented procedures for ensuring confidentiality. These procedures address both the 50001 SEP Verification Body as well as the individual auditor/verifier. Subcontracted or outsourced activities are subject to the same requirements.

1 The number of EnMS-effective personnel (those who are actively contributing to fulfilling EnMS requirements) is used by the chosen 50001 SEP Verification Body to determine the number of audit days. Per ISO 50003-2014, the 50001 SEP Verification Body’s process for determining the number of EnMS effective personnel should consider top management, management representative(s); the energy management team; person(s) responsible for effective implementation of the EnMS activities and for delivering energy performance improvements through objectives, targets and action plans; persons responsible for achieving and maintaining the assigned energy objectives and targets at relevant functions, levels, processes or facilities within the organization; persons responsible for significant energy uses; and persons responsible for activities related to EnMS such as procurement, design, facility maintenance, training, measurement, management planning etc.

2 Visit the 50001 SEP web site for a list of approved Verification Bodies: [www.energy.gov/eere/amo/sep-and-iso-50001-certification-process#choose-a-VB]

3 This information is used per ISO 50003 by 50001 SEP Verification Bodies to help determine the number of audit days.

4 Facility staff that spends 50 percent or greater time on energy management.

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