5900-198 Statement of Energy Improvement

OMB Control No. 2060-0347
Expiration Date: XX/XX/XXXX
Approved while under OMB review

STATEMENT OF ENERGY IMPROVEMENT
Site Name
2018
For Baseline Period
beginning the 1st of: January

2018

Company/Owner Address (if different)
Name
Street Address
Address 2
City, State
ZIP

Site Address
Contact Name
Street Address
Address 2
City, State
ZIP

Energy Improvement

2nd Year
3rd Year
4th Year
1st Year
Final
Baseline
December December December December December December
Period Ending:
2018
2019
2020
2021
2022
2023
Site Electricity (MMBtu)
Site Thermal Energy (MMBtu)
Source Electricity (MMBtu)
Source Thermal Energy (MMBtu)
Total Source Energy (MMBtu)
Production Unit or Sq. Ft
Energy Intensity (MMBtu/Production Unit or Sq. Ft)
% Energy Intensity Reduction from Baseline
Annual Source Energy Avoided (MMBtu)
Annual CO2e Avoided (metric tons)

0.00
--

0.00

0.00

0.00

0.00

0.00

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A customized energy intensity metric, normalized for multiple factors,
has been entered directly into row 30.

Yes

No

The basis for calculating annual avoided CO2e emissions is:

Absolute

Intensity

Professional Verification
Certifier Name
Certifier Title
Address
Address 2
City, State ZIP
Phone Number
Professional Certifier Stamp/Seal

Certifier Signature

Based on my review, I certify that the information used in this
tool to generate the energy intensity reduction represented
on this statement is accurate.

For U.S. 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 average 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 5900-198