OMB Control No. 2060-0347

Date



	Plant name as it will appear on Certificate



	Company name as it will appear on Certificate



	

Corporate energy manager contact information

Name



	Title



	Organization



	Address 1

Address 2



	City



	State



	Zip code



	Email



	Phone



	

Organization/Plant Owner’s Chief Executive Officer information:

Name



	Title



	Organization



	Address 1

Address 2



	City



	State



	Zip code



	Email



	Phone



	

Professional Engineer information

Name



	Title



	Organization



	Address 1

Address 2



	City



	State



	Zip code



	Email



	Phone



	License number



	

Plant Owner information:

Company or Parent Company Name



	Address 1

Address 2



	City



	State



	Zip code



	Web address:



	Phone



	

NOTE:  Unless specified otherwise, all recognition materials (the bronze
plaque, the banner/flag graphic, and the letter of congratulations) will
be addressed to and sent to the Corporate Energy Manager at the location
specified above.  The letter of congratulations for the CEO will be sent
directly to the address provided for the CEO.

Please specify any other information/requests for distribution of
recognition materials in the space below.

The public reporting 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,
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 5900-265

 

Plant Award Specification Sheet

