5900-89 Statement of Energy Performance -Plants

							OMB No. Control 2060-0347 Expiration Date: XX/XX/XXXX Approved while under OMB review
			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
		Durham, NC		City, State
		27705		ZIP
		Automobile Engine Plant Energy Performance Indicator
		Version 1.1, Release 10/26/2018
		Energy Performance Score:		##
		GHG Savings (Kg CO2e)		##
		Source Energy Savings (MMBtu)		##
		Site Energy Savings (MMBtu)		##
		Professional Verification
		Professional Engineer Name
		Address
		Address 2
		City, State ZIP
		Phone Number:
		Email Address:
		License Number:
		Licensing State:				Professional Engineer Stamp
		EPI Verification - choose "Yes" for one option:				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.
	No	EPI attached for EPA review.
	No	EPI contains proprietary information and has been sent to the designated reviewer.
		NOTE:
		1. Applications for certification of plant energy performance to the US EPA must be made within 12 months of Period Ending date. Plants that apply for recertification must use the subsequent 12-month period of continuous data if the plant was certified the previous year, unless an exception has been discussed with and granted by the US EPA.  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:
		This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0347). Responses to this collection of information are voluntary (Section 103(g) Clean Air Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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