5900-383 Professional Engineer Verificaiton Checklist

Professional Engineer

Verification Checklist

OMB Control No. 2060-0347

Expiration Date: XX/XX/XXXX

Approved while under OMB review

Plant: Click or tap here to enter text.

Date: Click or tap here to enter text.

PE: Click or tap here to enter text.

Review location: Corporate Office ☐ Site Visit☐ Other ☐

If other is checked, please describe how the PE confirmed that the plant met the eligibility requirements for certification and the authenticity and completion of the data used in the EPI.

Click or tap here to enter text

Plant Physical Characteristics and Eligibility

The plant has established a formal certification file.	Yes☐ No☐
Where? Click or tap here to enter text.
The plant’s activities conform to the eligibility description in the EPI Instructions.	Yes☐ No☐
These plant activities are described in the certification file.	Yes☐ No☐
Relevant calculations of plant activities (e.g., space requirements) meet specified minimums in the EPI Instructions.	Yes☐ No☐
These plant calculations supporting eligibility are documented in the certification file.	Yes☐ No☐

Plant Operating Characteristics

All data are confirmed to belong to the plant named in the EPI and plant certification documents.	Yes☐ No☐
All data are confirmed to match the same 12-month time period specified on the Statement of Energy Performance.	Yes☐ No☐
The plant’s data is current (defined as within one year of the Period Ending Date on the Statement of Energy Performance).	Yes☐ No☐
All original source data (e.g., production records) has been reviewed to assure all data were correctly transcribed into a spreadsheet, database, etc.	Yes☐ No☐
If original source data are not available for review: Internal verification procedures have been verified by PE and are applied to any company databases used for applicable data.	Yes☐ No☐ NA ☐
All calculations made using the original source data have been reviewed to assure accuracy, correct conversion of units, and use of generally accepted and uniformly applied conversion factors.	Yes☐ No☐ NA☐
Annual totals resulting from all calculations match the values entered into the EPI.	Yes☐ No☐
Annual totals resulting from all calculations match the units specified in the EPI.	Yes☐ No☐
Inputs or calculations for other required plant physical characteristics (e.g., square footage, kilns) are consistent with source documents provided in the certification file.	Yes☐ No☐
All source data, calculations, and assumptions have been documented in the formal certification file. Note that referral to a company database is not adequate; the file includes a static record of data drawn from the database on the date of EPI completion (i.e., the date the EPI score and Statement of Energy Performance were produced).	Yes☐ No☐
All production metrics (e.g., quantities, capacities, labor hours) follow the procedure specified in the EPI instructions.	Yes☐ No☐
Source data, calculations, and documentation for all other data types (e.g. HDD/CDD) have been reviewed and documented in the formal certification file.	Yes☐ No☐ NA☐
For cement plants, all energy data was entered using High Heating Value.	Yes☐ No☐ NA☐
For cement plants, no slag/flyash/pozzolanic blends are produced at this plant.	Yes☐ No☐ NA☐

Energy Data

All data confirmed to belong to the plant are named in the EPI and plant certification documents.	Yes☐ No☐
All data confirmed to match the same 12-month time period are specified on the Statement of Energy Performance.	Yes☐ No☐
The plant’s data are current (defined as within 6 months of the Period Ending Date on the Statement of Energy Performance.	Yes☐ No☐
If not, why? Click or tap here to enter text.
All original source data (e.g., utility invoices) have been reviewed to assure all data were correctly transcribed into a spreadsheet, database, etc.	Yes☐ No☐
If original source data are not available for review: Internal verification procedures have been verified by PE and are applied to any company databases used for applicable data.	Yes☐ No☐ NA☐
All calculations made using the original source data have been reviewed to assure accuracy, correct conversion of units, and use of generally accepted and uniformly applied conversion factors.	Yes☐ No☐
Annual totals resulting from all calculations match the values entered into the EPI.	Yes☐ No☐
All source data, calculations, and assumptions have been documented in the formal certification file. Note that referral to a company database is not adequate; the file must include a static record of data drawn from the database on the date of EPI completion (i.e., the date the EPI score and Statement of Energy Performance were produced).	Yes☐ No☐
Annual totals resulting from all calculations match the units specified in the EPI.	Yes☐ No☐
All energy sources used at the plant are included in the EPI.	Yes☐ No☐
All energy sources follow the energy accounting procedure specified in the EPI instructions.	Yes☐ No☐
Calculations for energy transfers (purchased steam, compressed air) have been reviewed for accuracy.	Yes☐ No☐ NA☐

ENERGY STAR Energy Performance Score

All the required data have been entered into the EPI.	Yes☐ No☐
The data have been properly entered into the EPI.	Yes☐ No☐
The plant’s EPI score is 75 or higher.	Yes☐ No☐

PE Verification

The PE review of the plant has been documented (e.g., site visit vs. corporate office, date, personnel met with, findings/corrections/recommendations from the review).	Yes☐ No☐
The PE completed the Verification Checklist for submission to EPA, and added the original document to the formal certification file.	Yes☐ No☐
The PE signed, stamped – indicating if embossed, and provided the required license information on the Statement of Energy Performance for submission to EPA, and added the original document to the formal certification file.	Yes☐ No☐

Please note any company personnel involved in review:

Please comment on any answers marked no and note any findings, corrections, or recommendations from the review:

PE Signature:________________________________________

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 20 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 No. 5900-383