Nomination Cover Page For Govenors Awards For Enviromental Excellence {51656}

NOMINATION COVER PAGE FOR GOVERNOR'S AWARDS FOR ENVIRONMENTAL EXCELLENCE State Form 51656 (R4 / 12-12) Indiana Department of Environmental Management Office of Pollution Prevention and Technical Assistance 100 North Senate Avenue Indianapolis, IN 46204-2251 Telephone: (800) 988-7901 Fax: (317) 233-6573 http://www.in.gov/idem/5147.htm INSTRUCTIONS: The Governor's Award Nomination Form is designed to satisfy environmental clearance requirements and Nominee clarification. Nominator should consult IDEM's website to see instructions on all forms and to increase chances of improving scores. Read "How to Complete and Submit a Nomination" at http://www.IN.gov/idem/5147.htm. Fill in the information requested below. Failure to provide all the requested information may disqualify your nomination. If you have questions about the awards program or need assistance with completing a nomination, call the Indiana Department of Environmental Management's Office of Pollution Prevention and Technical Assistance (OPPTA) at (800) 988-7901. All nominations must be received by OPPTA by the date and time set forth in the program guidelines at the above web address. Late nominations will not be accepted. Please type. PROJECT INFORMATION Award Category: Name of Project: Name that would appear on award: Start Date of Project (month, day, year): Name of Organization: Address (number and street): City: County: Type of organization being nominated: (Check the appropriate box.) Government School University Hospital Non-profit Business Industry Individual Current Date (month, day, year): End Date of Project (month, day, year): Federal ID Number: ZIP Code: Number of Employees: NOMINEE CONTACT INFORMATION Contact person: (Check the appropriate box.) First name: Last name: Telephone Number: E-Mail Address: Cell Telephone Number: Mr. Ms. Mrs. Dr. Middle Initial: PERSON SUBMITTING NOMINATION CONTACT INFORMATION Contact person: (Check the appropriate box.) First name: Last name: Telephone Number: (include area code) E-mail Address: Cell Telephone Number: Yes No Mr. Ms. Mrs. Dr. Middle Initial: If the nomination form was not submitted by the nominee, is the nominee aware they've been nominated? INSTRUCTIONS: The Clearance and Background Check Section is designed to satisfy environmental clearance requirements and speed up the review process by providing the permit number and/ or past violations. Nominator should consult OPPTA's Technical Assistance Branch at (800) 988-7901 to review any of these questions. PLEASE NOTE: This section may not be applicable to all projects nominated. CLEARANCE AND BACKGROUND CHECK INFORMATION Air Permit Number: Wastewater NPDES Permit Number: Drinking Water PWSID Permit Number: Storm Water Permit Number: Hazardous Waste EPA ID Number: Any Spills in the Last Five Years? If yes, please describe the spill and corrective action taken. Type: IDEM Type: Rule 5 Yes Rule 6 No MS4 Generator Status: Municipality Date (month, day, year): Date (month, day, year): Date (month, day, year): Date (month, day, year): Date (month, day, year): Date (month, day, year): Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: In the box below, provide a brief summary of the project or individual being nominated. For guidance on writing the project summary, read the instructions at http://www.IN.gov/idem/5147.htm or call OPPTA at (800) 988-7901. PROJECT SUMMARY INSTRUCTIONS: Please use this section for guidance on writing the project deliverables to convey the essentials of the project to the Review Committee. Applicants and nominees are encouraged to strengthen their project's nomination by using the additional selection criteria under their category, as listed under the Common Questions Section, at http://www.IN.gov/idem/5147.htm or call OPPTA at (800) 988-7901. PROJECT SELECTION CRITERIA 1) 2) 3) 4) 5) 6) 7) 8) A full description of the project, along with a brief project summary An explanation of how the project serves to advance environmental excellence The project's economic benefits and savings, in detail How the project has improved the community or workplace How the project reflects leadership commitment to these improvements How the project can be transferred to other organizations The features that make the project outstanding The project's overall environmental impact Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No ADDITIONAL ATTACHMENTS Nomination must provide the following attachments to assist in the project review and grading: Pictures of project being implemented or event List of environmental benefits with quantitative results Applicant understands that this information is public and will be shared with other entities Parent corporation's name: Any former names used by company? Previous years applied and categories? Yes Yes Yes Attached No No No Note: Information submitted in nominations and subsequent work product for Governor's Awards becomes public record. **DO NOT WRITE BELOW THIS LINE** THE BELOW CHECKLIST IS FOR THE BRANCH CHIEF PRE-SCREENING INSTRUCTIONS: All Governor's Awards Nominations are to be evaluated according to the criteria below. Any Nomination that does not receive a positive check mark on all criteria will not be eligible for consideration for a Governor's Award. PRE-SCREENING CRITERIA Does the nomination cover page have information in all required fields? Is the nominee located in Indiana? Does the project focus on a significant environmental activity in one of the award categories? Was the project completed in one of the previous two years prior to the nomination round? Does the project demonstrate at least one year of quantifiable results in a clear manner? Is the project voluntary, not the result of mandates by regulations or enforcement decrees? Was the nomination received by IDEM by the stated deadline? Yes Yes Yes Yes Yes Yes Yes No No No No No No No Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com