Award Recipients Will Be Selected Based On

Bronze Achiever Level

Colorado Environmental Leadership Program (ELP) Application

The Colorado Environmental Bronze Achievement Award is designed to recognize businesses, municipalities, or facilities that have made significant achievements in improving the environment of Colorado. The areas of achievement, which must be beyond compliance, may include one or more of the following: Improving air quality; Improving water quality; Reducing water usage; Reducing waste; Reducing energy usage; Energy Star achievements; Pollution prevention/Sustainability actions or other innovative measures that benefit Colorado’s environment and/or communities.

Forms are accepted throughout the year – in order to be recognized in the current year, nominations must be submitted by June 30th of each year.

Award recipients will be selected based on: 1 1. The strength of the nomination, including the environmental outcome of the achievement(s), 2 2. The scope of the achievement(s) or improvement(s), and 3 3. General enforcement history (total compliance is not required and will be researched by CDPHE).

E-mail: [email protected] Phone: (303) 692-3477 ELP Website

Section 1 - General Information - Please do not include any Confidential Business Information (CBI).

Company Name:

Name of Parent Company (if applicable):

Company Contact Name:

Company Contact E-mail Address:

Address:

City: Zip Code:

Phone Number:

Company Website Address:

Company Sector type (ex: manufacturing, government, agriculture, etc.)

SIC Code - List the Standard Industrial Code (SIC) code(s) that you use to classify business at your facility. For help see the following link: http://www.osha.gov/pls/imis/sic_manual.html (Please note, this is different than a NAICS code).

Section 2 - Please describe the achievement(s), including when the achievement was attained; and any quantifiable reductions or improvements (e.g., cost savings, gallons of water reduced, please do not use percentages). (feel free to send attachments):

Attached separately (if not please describe below).

Section 3 - Company/Business Information for website and PR materials

As an ELP member, you will get your own company profile on the ELP website. To see an example, please go to the following link and click on the different levels and actual companies: ELP Company Profile Link

Please describe what you do or make at your facility. Ensure to include your environmental/sustainable achievement and what you’d like the outside world to know about your company from a sustainability standpoint. (There is no limit to the size/character count of your written material). The environmental/sustainable icons will be added to your page, based on the achievements you list in your profile. This can also be sent as an attachment.

Attached separately (if not please describe below).

Company pictures and logo for website and PR materials

Please email two pictures, which represent your company. They will be used for the ELP website and PR materials. Please ensure they are of good quality.

Please email your company logo.

Section 4 - Community and Social Goals

1. Please report if your company participated in any Environmental Improvement Activities with your surrounding community? These are activities which help improve the community/neighborhood in the vicinity of your company location. Please check all that apply and describe the activity below.

Held a community e-waste event and/or household waste collection. Please specify:

Participated in a neighborhood/park beautification project. Please specify:

Work with local businesses or neighborhoods to develop recycling programs, etc. Please specify:

Establish a wildlife habitat program that includes employees and local groups (raptor breeding, etc.). Please specify:

IN.ELP.003 ELP Bronze Application 2 1/9/17 Participate in environmental clean-up projects in the community, involving employees, employee families and/or members of the community. (e.g., Scout troops, 4-H, etc.). Please specify:

Donate goods or services to a non-profit or businesses. Please specify:

Donate money to a local or national organization. Please specify:

Work with local groups to acquire and preserve land. Please specify:

Other, Please specify:

2. Please report if your company held any Environmental Education Activities within your community. Please check all that apply and please describe below.

Host or sponsor a tour that explains your environmental impacts, EMS's, etc.. Please specify:

Participate in exchange and recycling programs with local area schools. Please specify:

Provide environmental focused tours of your operations. Please specify:

Partner with high schools to offer students to shadow with environmental staff. Please specify:

Hold environmental seminars to educate other companies, teachers, etc.. Please specify:

Sponsor and/or hold environmental/science scholarship opportunities for students. Please specify:

Partner with local wildlife group(s) and/or non-profits. Please specify:

Other Please specify:

3. Please report if your company has done any Environmental Mentoring? Please check all that apply and please describe below.

Provide voluntary assistance to local businesses to help them achieve compliance regarding processes or permits. Please specify:

Commit staff and/or funding to mentor another business to develop and/or implement their EMS.

IN.ELP.003 ELP Bronze Application 3 1/9/17 Please specify:

Form a Citizens' Advisory Panel (CAP) who meet regularly to discuss and address environmental issues. Please specify:

Volunteer staff to serve on or establish an environmental committee for your city/local community. Please specify:

Institute an environmental audit program with local government. Please specify:

Attend County Commission meetings and provide updates. Please specify:

Volunteer employees to sit on a Commission or Board. Please specify:

Donate your location for an information get-together for local businesses with an environmental focus. Please specify:

Other, please specify:

Section 5 - Environmental Requirements Information Please list any major Federal, State, tribal, and local environmental permits your company may have.

a. Air Pollution Permit Numbers Please list any air permit ID numbers (Federal, State, tribal or local) Not applicable ID Numbers (specify whether State or Federal).

b. Hazardous and/or Solid Waste Permit Numbers Please list any Hazardous or Solid Waste permit ID numbers (Federal, State, tribal or local) Not applicable ID Numbers (specify whether State or Federal).

c. Water Pollution Control Permit Numbers Please list any Water Pollution permit ID numbers (Federal, State, tribal or local) Not applicable ID Numbers (specify whether State or Federal).

d. Additional Environmental Related Permit Numbers Please list any permit ID numbers (Federal, State, tribal or local) not stated above Not applicable ID Numbers (specify whether State or Federal).

IN.ELP.003 ELP Bronze Application 4 1/9/17 IN.ELP.003 ELP Bronze Application 5 1/9/17 Section 6 - Application and Participation Statement

You may email this signed page as a pdf file (please e-mail the rest of the application).

On behalf of [Company /Business Name]

I certify that

I have read and agree to the terms and conditions for Application and Participation in the Colorado Environmental Leadership Program, as specified in The Colorado Environmental Leadership Program Handbook;

• 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 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 the state’s decision whether to accept participants into or remove them from the Bronze Achiever Membership is wholly discretionary, and I waive any right that may exist under any law to challenge the state’s acceptance or removal decision.

Printed Name Title

Signature Date

E-Mail Phone Number (include area code)

IN.ELP.003 ELP Bronze Application 6 1/9/17