Free IDEM Web site PDF Justification form - Indiana

INDIANA ENVIRONMENTAL STEWARDSHIP PROGRAM APPLICATION
State Form 52772 (R / 2-07)

Indiana Department of Environmental Management Environmental Stewardship Program

Indiana Department of Environmental Management Office of Pollution Prevention & Technical Assistance 100 North Senate Avenue IGCS W041 Indianapolis, Indiana 46204-2251 Telephone: (800) 988-7901 Fax: (317) 233-5627 E-mail: [email protected]

When to use this application form... STOP! Is your facility currently a member or planning to become a member of the U.S. Environmental Protection Agency's National Environmental Performance Track Program (NEPT)? If your facility is currently a NEPT member, please contact IDEM at 800-988-7901 for application information before proceeding. If your facility wishes to become a member of NEPT and the Indiana Environmental Stewardship Program (ESP), do not complete this application. Use the NEPT application found at: www.epa.gov/performancetrack/apps/app.htm. The U.S. EPA will notify IDEM of your application to both ESP and NEPT. GO! Please use this form when you are applying only to the Indiana Environmental Stewardship Program. E-mail the completed application to the Indiana Department of Environmental Management (IDEM) at [email protected]. IDEM will notify you of receipt.

Your application should be reviewed and signed by a senior manager at your facility prior to submittal. The Application and Participation Statement must be signed by a senior manager at the facility and faxed, e-mailed, or mailed to IDEM. If you have any questions, please contact IDEM at [email protected] or 800-988-7901.

APPLICANT INFORMATION Name of Facility* Name of Parent Company** Facility Location, Street Address Facility Location, City/State/ZIP code If your facility has multiple street addresses, please list any other addresses for its sites or buildings:

* The name you enter for your facility will appear on all documents pertaining to ESP participation, which can include, but is not limited to: acceptance certificates, ESP membership directories, press releases, alphabetized lists on IDEM web sites, and so on. If your company has or will have multiple members in the program, we suggest facility names are provided that distinguish the facilities from one another. **Please note that any parent company listed will not appear on ESP documentation. If it is important that your parent company appear in the facility's title, then please include it in the facility name above. CONTACT INFORMATION Contact Name (Mr./Mrs./Ms./Dr.) Title Phone Fax E-mail Facility/Company Website Mailing Address (if different from street address) City/State/ ZIP code

SECTION A ABOUT YOUR FACILITY Why do we need this information? IDEM needs background information on your facility to evaluate your application. 1 In what ways have you learned about ESP? (Select all that apply) At a professional conference Marketing mailer Through a trade association Market phone call or e-mail Internally within your company News media / professional journal From a peer in your sector Environmental consultant Internet/website Other (please specify) 2 What do you do or make at your facility?

What do you need to do? Provide background information on your facility Identify your environmental requirements

3 List your facility's Federal Identification number.

4 List the North American Industrial Classification System (NAICS) codes you use to classify business at your facility.

5 How many employees (full-time equivalents) currently work at your facility? Fewer than 50 50-99 100-499 500-1,000 More than 1,000 6 If there is something else you would like to tell us about your facility (e.g., receipt of environmental awards, participation in other voluntary programs at the local, tribe, state, or federal level), please describe them here.

SECTION B ABOUT YOUR EMS Why do we need this information? Facilities need to have implemented an approved environmental management system (EMS) that meets certain criteria.

What do you need to do? Confirm your EMS meets the ESP criteria Confirm you have had an independent assessment of your EMS

1 Are you a Responsible Care-certified facility? Yes. If yes, please answer these supplementary questions regarding your Responsible Care certification: Please indicate whether your certification is to: RC EMS RC 14001 Are you a member of the American Chemistry Council (ACC)? Yes No Are you a member of the Synthetic Organic Chemical Manufacturers (SOCMA)? Yes No Responsible Care-certified facilities may now skip to Section C. No. If no, please continue to question 2.

2 Read the EMS requirements in the ESP Application Instructions and tell us if your EMS meets the requirements for: Environmental Policy Yes No Planning Yes No Implementing and operation Yes No Checking and corrective action Yes No Management review Yes No Public Outreach Yes No 3 Have you done a comprehensive review of all activities conducted at your facility that could impact the environment (i.e., have you completed an aspect analysis)? Yes No 4 Have you classified your aspects based on their potential harm to the environment, on community concerns, and/or on other objective factors (i.e., have you determined your significant aspects)? Yes No 5 When did you last update your aspect analysis? (mo/yr) 6 Have you implemented the EMS (plan-do)? Yes No 7 Has your EMS been assessed by an independent party or certified by a recognized standard? Yes. If yes, what method of EMS assessment did you use? IDEM or duly authorized agent of IDEM ISO 14001:2004 Certification (Please provide copy of most recent certificate) Other, please specify No 8 What was the date of your last independent EMS assessment (mo/yr)? 9 Who performed the independent assessment?

SECTION C ENVIRONMENTAL IMPROVEMENT INITIATIVES Why do we need this information? What do you need to do? Facilities need to show they are committed to improving their Refer to the Environmental Performance Table in the environmental performance. instructions. For ESP membership, you must identify three (3) environmental improvement initiatives for each 3-year membership term. One (1) initiative must be identified in this application and the remaining initiatives shall be identified each year at the time the annual summary is submitted to IDEM. In the following table, identify the initiative that will begin this year. The initiative will be measured by the environmental indicator you select. You must choose an indicator from the Environmental Performance Table as provided in the ESP Application Instructions. The indicator you select for your initiative should be related to the objectives and targets in your EMS. Where possible, indicators also should be identified as having a significant environmental impact in your EMS. No more than two of your indicators can be from the same environmental category during the 3-year term. If you are not sure how your objectives and targets fit into the indicators from the Environmental Performance Table or whether your indicators are significant, call IDEM at 800-988-7901. Please complete the following questions according to the environmental indicator you selected from the Environmental Performance Table. Additional information is required for air, hazardous waste, solid waste, and energy indicators as requested in Appendix 1. 1a What category have you selected from the Environmental Performance Table? (If the category is Energy Use, Waste, or Air Emissions for Total GHGs, please turn to Appendix 1 to complete additional questions pertaining to the category you have selected.) 1b What indicator have you selected from the Environmental Performance Table?

1c All measurements should represent the performance level for the indicator across the entire facility. For many indicators, you may choose to focus your initiative on a specific subset of the indicator (e.g., a specific material, process, VOC, group of toxic air emissions, or particular waste component). Does your initiative include everything covered by the indicator (e.g., all VOCs, all non-hazardous waste), or a specific process, substance, or component (e.g., ethane, cardboard)? All Specific

If your initiative is specific to a substance or component, please provide additional detail on your indicator (e.g., specific chemical to be reduced, specific waste component).

1d What activities or process changes do you plan to undertake at your facility to accomplish your initiative (e.g., technology changes in a particular process line, employee training)?

2a Does this initiative address a significant aspect in your EMS? Yes No 2b If no, please explain why you believe this indicator should be included as an environmental improvement initiative.

Stop! If the category listed in Question 1a is Energy Use, Waste, or Air Emissions for Total GHGs, please skip Questions 3a ­ 3b below and turn to Appendix 1 to complete the questions pertaining to the category you listed. After completing Appendix 1, return to question 4 and complete the remaining application questions. 3a What units are you using to quantify this indicator? (Please refer to the Environmental Performance Table for the acceptable units for each indicator.) 3b List the baseline annual quantity of the indicator and the annual quantity you are committing to achieve by the future year. Baseline quantity Year Year Future year quantity (not including production) 4 Does the quantity presented in the future quantity column represent an absolute goal or a normalized goal? Normalized goal (i.e., indexed to level of business in baseline year) Absolute goal (i.e., demonstrates improvement even if production increases) 5 Whether your goal is absolute or normalized, you will need to provide normalizing factors and normalized quantities in your annual performance reports. Please briefly describe your basis for normalizing. Examples of potential normalizing basis include: gallons of paint produced, square feet of circuit boards sold, number of patients seen, dollars of sales adjusted for inflation, or number of employees (for R&D and administrative sites only).

6a Are you subject to Federal, State, tribal, or local regulatory requirements for this indicator? Yes No 6b If yes, explain how your initiative exceeds regulatory requirements.

APPENDIX 1 ENVIRONMENTAL PERFORMANCE DATA Additional questions for environmental improvement initiatives for the following categories/indicators: Energy Use - Non-Transportation In the table below, please enter the amount of energy that you currently use and that you intend to use in your future reporting year. Break the energy use down by fuel type. Please note that you need only complete those lines that are relevant to your facility. If all of your energy is purchased from a local electricity generator, you may only need to complete the first line. If the facility uses natural gas, please be sure to complete the appropriate line (natural gas is typically combusted on site so it is listed in the "onsite" section). Please note that this table categorizes sources of energy according to where the energy is generated. 3a Is the goal of your energy use commitment to: Reduce total energy use Invest in renewable energy sources Combination of both strategies 3b How much energy of each type does your facility use? Baseline Year 20 Electricity Steam Total Energy Generated Off-Site Coal Natural Gas Crude Oil Fuel Oil Diesel Propane / LPG Gasoline Hydrogen Powered Fuel Cells Sources of Natural Gas / Methane Powered Energy Fuel Cells Generated Biomass On-Site Solar Wind Landfill Gas Geothermal Hydroelectric Tire Derived Fuel Other Fuel or Source Specify: Total Energy Generated On-Site Total Renewable Energy Use Total Non-Renewable Energy Use Total Energy Use Metric Tons of CO2 Equivalents Metric Tons of CO2 Equivalents Offset Through Purchases of Electricity from Renewable Off-Site Sources Net Metric Tons of CO2 Equivalents Energy Generated Off-Site Waste - Non-Hazardous Waste Generation In the table below, please enter your facility's amount of non-hazardous waste, broken down by waste management method. Please enter both the amounts you manage currently and that you intend to manage in your future reporting year. "Waste" is defined as all materials sent off-site that are neither product nor product packaging. 3a Is the goal of your non-hazardous waste commitment to: Reduce non-hazardous waste Improve waste management methods Combination of both strategies 3b How much of your waste is handled using each management method? Method of Waste Managed Baseline Year 20 Landfill Incineration Reused/recycled off-site Other management - Specify: Total Non-Hazardous Waste Future Year 20 Units

Future Year 20

Units

Waste - Hazardous Waste Generation In the table below, please enter your facility's amount of hazardous waste, broken down by waste management method. Please enter both the amounts that you manage currently and that you intend to manage in your future reporting year. Include all hazardous waste that is treated on-site or sent off-site. 3a Is the goal of your hazardous waste commitment to: Reduce hazardous waste Improve waste management methods 3b How much of your hazardous waste is handled using each management method? Method of Waste Managed Landfill Incineration Reused/recycled off-site Treated on-site Other management Specify: Total Hazardous Waste Air Emissions ­ Total GHGs 3a Is the goal of your Total GHGs commitment to: Reduce energy use Reduce process-related emissions 3b How much greenhouse gas does your facility emit from each source? Source Stationary Combustion Mobile Sources Refrigeration/AC Equipment Use Process/Fugitive Specify Source: Process/Fugitive Specify Source: Process/Fugitive Specify Source: Total Direct Emissions Process/Fugitive Purchased Electricity Purchased Steam Purchased Hot Water Total Indirect Emissions Other Specify Source: Other Specify Source: Other Specify Source: Total Optional Indirect Emissions Offsets Specify Source: Offsets Specify Source: Offsets Specify Source: Total Reductions from Offsets Total Emissions Less Offsets Total CFC Total HCFC Total Stationary Combustion ­ Biomass CO2 Total Mobile Sources ­ Biomass CO2 Electricity trading transactionsElectricity Purchase for Resale Baseline Year 20 Future Year 20 Units Baseline Year 20 Future Year 20 Units

Combination of both strategies

Combination of both strategies

Direct Emissions

Indirect Emissions

Optional Indirect Emissions

Offsets

Supplemental Information

APPLICATION AND PARTICIPATION STATEMENT Print and complete this page. Send a signed copy of this page to IDEM via fax, mail, or scan and e-mail.

On behalf of I certify that: · I have read and agree to the terms and conditions for Application and Participation in the Indiana Environmental Stewardship Program, as specified in the Indiana Environmental Stewardship Program Guidelines and Application Instructions; · I have personally examined and am familiar with the information contained in this Application, including the Environmental Requirements Checklist. The information contained in this Application is, to the best of my knowledge and based on reasonable inquiry, true, accurate, and complete, and I have no reason to believe the facility would not meet all program requirements; · My facility has an environmental management system (EMS), as defined in the Indiana Environmental Stewardship Program EMS requirements, including systems to maintain compliance with all applicable Federal, State, tribal, and local environmental requirements in place at the facility, and the EMS will be maintained for the duration of the facility's participation in the program; · My facility has conducted an objective assessment of its compliance with all Federal, State, tribal, and local environmental requirements, and the facility has corrected all identified instances of potential or actual noncompliance; · Based on the foregoing compliance assessment and subsequent corrective actions (if any were necessary), my facility is, to the best of my knowledge and based on reasonable inquiry, currently in compliance with applicable Federal, State, tribal, and local environmental requirements. I agree that IDEM's decision whether to accept participants into or remove them from the Indiana Environmental Stewardship Program is wholly discretionary, and I waive any right that may exist under any law to challenge IDEM's acceptance or removal decision. I am the senior facility manager or authorized facility signatory, and fully authorized to execute this statement on behalf of the corporation or other legal entity whose facility is applying to this program. Signature/Date Printed Name Title Phone Number/E-mail Facility Name Facility Street Address City/State/Zip Code Mailing Address (if different from facility location): City/State/Zip: ____________________________________________________ Mr./Mrs./Ms./Dr.

Please e-mail your completed application and attachments to [email protected]. Please provide IDEM with a signed version of the Application and Participation Statement. Once signed, this statement may be faxed, mailed, or e-mailed to IDEM at:

IDEM ­ OPPTA Attn: ESP Application 100 North Senate Avenue MC 64-00 IGCS W041 Indianapolis, Indiana 46204-2251 Fax: 317-233-5627 [email protected]