NOMINATION COVER PAGE FOR GOVERNOR’S AWARDS FOR ENVIRONMENTAL EXCELLENCE Office of Pollution Prevention and Technical Assistance 100 North Senate Avenue Indianapolis, IN 46204-2251 Telephone: (800) 988-7901 Fax: (317) 233-5627 State Form 51656 (R3 / 12-10) Indiana Department of Environmental Management 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 or (317) 232-8172. 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: Current Date (month, day, year): Project’s Name: Name that would appear on award: Project Start Date (month, day, year): Project End Date (month, day, year): Organization’s Full Name: Federal ID Number: Address (number and street): City: ZIP Code: County: Number of Employees: Type of organization being nominated: (Check the appropriate box.) Government School University Hospital Non-profit Business Industry Individual NOMINEE CONTACT INFORMATION Contact person: (Check the appropriate box.) Mr. Ms. First name: Mrs. Dr. Mrs. Dr. Middle Initial: Last name: Telephone Number: Cellular Telephone Number: E-Mail Address: PERSON SUBMITTING NOMINATION CONTACT INFORMATION Contact person: (Check the appropriate box.) Mr. Ms. First name: Middle Initial: Last name: Telephone Number (include area code): Cellular Telephone Number: E-mail Address: If the nomination form was not submitted by the nominee, is the nominee aware they’ve been nominated? Yes No 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 or (317) 232-8172 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: Type: IDEM Date (month, day, year): Municipality Type: Rule 5 Date (month, day, year): Date (month, day, year): Rule 6 Date (month, day, year): Drinking Water PWSID Permit Number: Type: Date (month, day, year): Hazardous Waste EPA ID Number: Generator Status: Date (month, day, year): Yes No Any spills in the last five (5) years? If yes, please describe the spill and corrective action taken. 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 or (317) 232-8172 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 Narrative Guide Section, at http://www.IN.gov/idem/5147.htm or call OPPTA at (800) 988-7901 or (317) 232-8172. PROJECT SELECTION CRITERIA 1) A full description of the project, along with a brief project summary Yes No 2) An explanation of how the project serves to advance environmental excellence Yes No 3) The project’s economic benefits and savings, in detail Yes No 4) How the project has improved the community or workplace Yes No 5) How the project reflects leadership commitment to these improvements Yes No 6) How the project can be transferred to other organizations Yes No 7) The features that make the project outstanding Yes No 8) The project’s overall environmental impact Yes No ADDITIONAL ATTACHMENTS Attached Nomination must provide the following attachments to assist in the project review and grading: Pictures of project being implemented or event Yes No List of environmental benefits with quantitative results Yes No Applicant understands that this information will be shared with other entities Yes No Parent corporation’s name: Any former names used by company? Previous years applied and categories? **DO NOT WRITE BELOW THIS LINE** THE BELOW CHECKLIST IS FOR THE BRANCH CHIEF PRE-SCREENING INSTRUCTIONS: All Governors’ 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? Yes No Is the nominee located in Indiana? Yes No Does the project focus on a significant environmental activity in one of the award categories? Yes No Was the project completed in one of the previous two years prior to the nomination round? Yes No Does the project demonstrate at least one year of quantifiable results in a clear manner? Yes No Is the project voluntary, not the result of mandates by regulations or enforcement decrees? Yes No Was the nomination received by IDEM by the stated deadline? Yes No Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com