ENERGY STAR® Challenge for Industry Recognition Application

OMB Control Number 2060-0347

As the energy manager for my company and/or site, I am writing to nominate the following site for recognition for achieving the ENERGY STAR Challenge for Industry.

I affirm that this site meets the conditions necessary to qualify for the ENERGY STAR Challenge for Industry recognition by achieving a10% reduction in energy intensity within 5 years of establishing a baseline.

I have personally examined and am familiar with the information contained in the Statement of Energy Improvement. The information is based on reasonable inquiry and is, to the best of my knowledge, true, accurate, and complete. I have no reason to believe the site would not meet all EPA program requirements for receiving the ENERGY STAR Challenge for Industry recognition.

I understand the U.S. Environmental Protection Agency reserves the right to request and review any records which support the data used to calculate the energy intensity reduction for this site. I also certify that I am maintaining a file on this site in accordance with the ENERGY STAR Challenge for Industry data management requirements. Furthermore, I agree to associate the achievement of the ENERGY STAR Challenge for Industry only with the aforementioned site and to adhere to the ENERGY STAR Identity Guidelines.

IMPORTANT: Upon completing this online application form, you must submit the site’s signed
Statement of Energy Improvement and PE Verification Checklist to industrychallenge@energystar.gov to complete the application process.

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    Site Information

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    Site Contact

    Note: The Site Contact must be located within the U.S.
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    Corporate Energy Director

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    Chief Executive Officer

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    Other Contact (optional)

    If you wish to have a third person, such as the plant manager at an international plant, named in the congratulatory letter, please identify that person here.
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    Questions and Mailings

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    The public reporting burden for this collection of information is estimated to average 10 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 Number 5900-262 BEFORE YOU CLICK SUBMIT: Using your browser’s Print function, please print this completed form to a PDF or paper and retain for your Formal Site File. Then click Submit.
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