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NPEP Online Enrollment Form

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Partner Agreement

Our organization is choosing to become a partner in EPA's National Partnership for Environmental Priorities. Our goal is to reduce the quantity of one or more Priority Chemicals currently found in our products, processes, or releases using techniques such as source reduction, recycling, or other materials management practices. We may propose projects that do not contain Priority Chemicals, but will still result in a significant environmental improvement. In this enrollment application, we identify one or more voluntary goals that we believe we can achieve as partners in this program.

OMB No. 2050-0190
Expiration Date: 5/31/2009

The voluntary goal(s) provided below is an initial estimate and may change over time. We may revise our goal(s) or withdraw from the program at any time. If/when we choose to revise our goals or withdraw from the program, we will notify EPA.

Identifying Information

View example enrollment form (PDF) (1 pg, 46K, About PDF)
Name of Organization:   Facility Name:
Principal Contact:   Title:
Address Line1:   Address Line 2:
City:   State:
Zip:      
Phone:   Fax:
E-mail:   EPA RCRA ID Number:

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Goals

This online enrollment form allows you to submit up to five goals at one time. If you have more than five goals, submit your first five, then re-open the form and continue describing your goals. EPA will publicly recognize the achievement of each goal you reach.

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Goal #1. The Priority Chemical selected for this goal is:
 


Choose "other" if the chemical is not a Priority Chemical and provide the chemical and CASRN in the boxes below.

   Other - Chemical Name:  
  Other - CASRN:  

Narrative Description of Proposed Project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of the proposed project and the product or
process it will impact (limit 250 characters).

How We Will Measure Success. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of how you will measure success (limit 200 characters).

Source Reduction Information for this Chemical. View example enrollment form (
PDF) (1 pg, 46K, About PDF)
Our voluntary source reduction goal is to reduce the amount of this chemical from a baseline of

 
to a reduced amount of
(pounds of chemical generated/used per year)     (pounds of chemical generated/used per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this source reduction goal between
 
and  
(month/year)
    
     (month/year)

To accomplish this goal, we will use the following source reduction options (check all that apply).
Equipment or technology modifications.
Reformulation or redesign of products.
Improvements in inventory control.
Process or procedure modifications.
Substitution of less toxic raw materials.
Improvements in maintenance/ housekeeping practices.
Other (please describe below; limit 200 characters).
 

Recycling or Recovery Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
In addition to, or in lieu of using source reduction methods, our voluntary recycling or recovery goal for this chemical is to increase the recycled or recovered quantity of this chemical from
 
to 
(pounds per year)     (pounds per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this goal between
 
and  
(month/year)
           (month/year)

To accomplish this goal, we will use the following recycling or recovery options (check all that apply).
Direct use/reuse in a process to make a product.
Processing waste to recover or regenerate a usable product.
Using/reusing waste as a substitute for a commercial product.
Other (please describe below; limit 200 characters).
 

Quality Assurance Plan
We have a Quality Assurance/Quality Control Plan for data.

Yes
No

Authorizing Official for this goal:
Name: Title: Date:

If you would like to propose additional goals for this chemical, or goals for additional chemicals (optional, not required for enrollment), skip the "Submit Goals Now" button, and go on to the next section. Otherwise, submit your application now by clicking once on the "Submit Goals Now" button.          

Back to Beginning of Goal #1

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Goal #2. The Priority Chemical selected for this goal is:
 


Choose "other" if the chemical is not a Priority Chemical and provide the chemical and CASRN in the boxes below.

   Other - Chemical Name:  
  Other - CASRN:  

Narrative Description of Proposed Project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of the proposed project and the product or
process it will impact (limit 250 characters).

How We Will Measure Success. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of how you will measure success (limit 200 characters).

Source Reduction Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Our voluntary source reduction goal is to reduce the amount of this chemical from a baseline of

 
to a reduced amount of
(pounds of chemical generated/used per year)     (pounds of chemical generated/used per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this source reduction goal between
 
and  
(month/year)
    
     (month/year)

To accomplish this goal, we will use the following source reduction options (check all that apply).
Equipment or technology modifications.
Reformulation or redesign of products.
Improvements in inventory control.
Process or procedure modifications.
Substitution of less toxic raw materials.
Improvements in maintenance/ housekeeping practices.
Other (please describe below; limit 200 characters).
 

Recycling or Recovery Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
In addition to, or in lieu of using source reduction methods, our voluntary recycling or recovery goal for this chemical is to increase the recycled or recovered quantity of this chemical from
 
to 
(pounds per year)     (pounds per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this goal between
 
and  
(month/year)
           (month/year)

To accomplish this goal, we will use the following options (check all that apply).
Direct use/reuse in a process to make a product.
Processing waste to recover or regenerate a usable product.
Using/reusing waste as a substitute for a commercial product.
Other (please describe below; limit 200 characters).
 

Quality Assurance Plan
We have a Quality Assurance/Quality Control Plan for data.

Yes
No

Authorizing Official for this goal:
Name: Title: Date:

If you would like to propose additional goals for this chemical, or goals for additional chemicals (optional, not required for enrollment), skip the "Submit Goals Now" button, and go on to the next section. Otherwise, submit your application now by clicking once on the "Submit Goals Now" button.          

Back to Beginning of Goal #2

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Goal #3. The Priority Chemical selected for this goal is:
 


Choose "other" if the chemical is not a Priority Chemical and provide the chemical and CASRN in the boxes below.

   Other - Chemical Name:  
  Other - CASRN:  

Narrative Description of Proposed Project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of the proposed project and the product or
process it will impact (limit 250 characters).

How We Will Measure Success. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of how you will measure success (limit 200 characters).

Source Reduction Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Our voluntary source reduction goal is to reduce the amount of this chemical from a baseline of

 
to a reduced amount of
(pounds of chemical generated/used per year)     (pounds of chemical generated/used per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this source reduction goal between
 
and  
(month/year)
    
     (month/year)

To accomplish this goal, we will use the following source reduction options (check all that apply).
Equipment or technology modifications.
Reformulation or redesign of products.
Improvements in inventory control.
Process or procedure modifications.
Substitution of less toxic raw materials.
Improvements in maintenance/ housekeeping practices.
Other (please describe below; limit 200 characters).
 

Recycling or Recovery Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
In addition to, or in lieu of using source reduction methods, our voluntary recycling or recovery goal for this chemical is to increase the recycled or recovered quantity of this chemical from
 
to 
(pounds per year)     (pounds per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this goal between
 
and  
(month/year)
           (month/year)

To accomplish this goal, we will use the following options (check all that apply).
Direct use/reuse in a process to make a product.
Processing waste to recover or regenerate a usable product.
Using/reusing waste as a substitute for a commercial product.
Other (please describe below; limit 200 characters).
 

Quality Assurance Plan
We have a Quality Assurance/Quality Control Plan for data.

Yes
No

Authorizing Official for this goal:
Name: Title: Date:

If you would like to propose additional goals for this chemical, or goals for additional chemicals (optional, not required for enrollment), skip the "Submit Goals Now" button, and go on to the next section. Otherwise, submit your application now by clicking once on the "Submit Goals Now" button.          

Back to Beginning of Goal #3

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Goal #4. The Priority Chemical selected for this goal is:
 


Choose "other" if the chemical is not a Priority Chemical and provide the chemical and CASRN in the boxes below.

   Other - Chemical Name:  
  Other - CASRN:  

Narrative Description of Proposed Project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of the proposed project and the product or
process it will impact (limit 250 characters).

How We Will Measure Success. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of how you will measure success (limit 200 characters).

Source Reduction Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Our voluntary source reduction goal is to reduce the amount of this chemical from a baseline of

 
to a reduced amount of
(pounds of chemical generated/used per year)     (pounds of chemical generated/used per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this source reduction goal between
 
and  
(month/year)
    
     (month/year)

To accomplish this goal, we will use the following source reduction options (check all that apply).
Equipment or technology modifications.
Reformulation or redesign of products.
Improvements in inventory control.
Process or procedure modifications.
Substitution of less toxic raw materials.
Improvements in maintenance/ housekeeping practices.
Other (please describe below; limit 200 characters).
 

Recycling or Recovery Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
In addition to, or in lieu of using source reduction methods, our voluntary recycling or recovery goal for this chemical is to increase the recycled or recovered quantity of this chemical from
 
to 
(pounds per year)     (pounds per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this goal between
 
and  
(month/year)
           (month/year)

To accomplish this goal, we will use the following options (check all that apply).
Direct use/reuse in a process to make a product.
Processing waste to recover or regenerate a usable product.
Using/reusing waste as a substitute for a commercial product.
Other (please describe below; limit 200 characters).
 

Quality Assurance Plan
We have a Quality Assurance/Quality Control Plan for data.

Yes
No

Authorizing Official for this goal:
Name: Title: Date:

If you would like to propose additional goals for this chemical, or goals for additional chemicals (optional, not required for enrollment), skip the "Submit Goals Now" button, and go on to the next section. Otherwise, submit your application now by clicking once on the "Submit Goals Now" button.          

Back to Beginning of Goal #4

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Goal #5. The Priority Chemical selected for this goal is:
 


Choose "other" if the chemical is not a Priority Chemical and provide the chemical and CASRN in the boxes below.

   Other - Chemical Name:  
  Other - CASRN:  

Narrative Description of Proposed Project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of the proposed project and the product or
process it will impact (limit 250 characters).

How We Will Measure Success. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Please provide a brief, detailed description of how you will measure success (limit 200 characters).

Source Reduction Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
Our voluntary source reduction goal is to reduce the amount of this chemical from a baseline of

 
to a reduced amount of
(pounds of chemical generated/used per year)     (pounds of chemical generated/used per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this source reduction goal between
 
and  
(month/year)
    
     (month/year)

To accomplish this goal, we will use the following source reduction options (check all that apply).
Equipment or technology modifications.
Reformulation or redesign of products.
Improvements in inventory control.
Process or procedure modifications.
Substitution of less toxic raw materials.
Improvements in maintenance/ housekeeping practices.
Other (please describe below; limit 200 characters).
 

Recycling or Recovery Information for this Chemical. View example enrollment form (PDF) (1 pg, 46K, About PDF)
In addition to, or in lieu of using source reduction methods, our voluntary recycling or recovery goal for this chemical is to increase the recycled or recovered quantity of this chemical from
 
to 
(pounds per year)     (pounds per year)

Timeline for this project. View example enrollment form (PDF) (1 pg, 46K, About PDF)
We will accomplish this goal between
 
and  
(month/year)
           (month/year)

To accomplish this goal, we will use the following options (check all that apply).
Direct use/reuse in a process to make a product.
Processing waste to recover or regenerate a usable product.
Using/reusing waste as a substitute for a commercial product.
Other (please describe below; limit 200 characters).
 

Quality Assurance Plan
We have a Quality Assurance/Quality Control Plan for data.

Yes
No

Authorizing Official for this goal:
Name: Title: Date:

This form allows you to submit five goals at one time. If you have more than five goals, submit your first five, then re-open the form and continue describing your goals.             

Back to Beginning of Goal #5

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