Gold Level Renewal Application

Colorado Environmental Leadership Program (ELP)

Renewal Requests are due by June 30th of the anniversary year. Gold Level renewal occurs every third year of membership. Applicants are encouraged to submit forms electronically.

E-mail: lynette.myers@state.co.us 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 Street Address (number and street)

City

State

Zip Code

County

Name/Title contact Person

E-Mail

Telephone Number (include area code)

Mailing Address if different than above

Number of full time EmployeesNote: fewer than 50 employees is considered a "small business" by the Environmental Leadership Program.

Number of Part Time employees

Company Website

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).

*The name entered for the company will appear on all documents pertaining to the Colorado Environmental Leadership Program (ELP), which can include but is not limited to: acceptance certificates, ELP Directors, press releases, alphabetized lists on Colorado websites, etc. If your company has or will have multiple members in the program, it is suggested that facility names be provided which distinguish the facilities form one another.

**Please note, that any parent company listed here will not appear on ELP documentation. If it is important that you parent company appear in the company’s title, then please include it in the company name above.

Section 2 - Company/Business Information for website and PR materials

Please update your company profile which is shown on the ELP website. To see your company’s profile, please go to the following link: ELP Company Profile Link

Please note: There is no limit to the size/character count of your written description. You can revise as necessary. Ensure you continue to describe what you do or make at your facility and your environmental/sustainable achievements and what you’d like the outside world to know about your company from a sustainability standpoint. Also, the environmental/sustainable icons will be added to your page, based on the achievements you list in your profile. The profile can be sent as an attachment.

Attached separately (if not please describe below).

Section 3 – Update your 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 PRmaterials. Please ensure they are of good quality.

Please email your company logo if it has changed since last year.

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Section 4 – Environmental/Sustainable Management System (EMS) Information

Current EMS Systems

1. Does your facility have any of the following certifications:

ISO 14001:2005 certification: No Yes --- If yes, Date of Certification:

ISO 14001:2015 certification: No Yes --- If yes, Date of Certification:

EMS Responsible Care-certification: No Yes --- If yes, Date of Certification:

Actively Green Certified : No Yes --- If yes, Date of Certification:

Practice Greenhealth : No Yes --- If yes, Date of Certification:

Certifiably Green Denver : No Yes --- If yes, Date of Certification:

Other:

Internal EMS Audits

1. Date of last EMS audit (plan-do-check-act)? Date:

3. Did this cycle include an internal regulatory compliance audit? Yes No

4. How often are your internal audits scheduled?

Management Review1. Date of your last Management Review Meeting - (meeting with upper management to review your EMS, Results

of audits, goals, corrective actions, etc.)?

External - Third Party EMS Audits

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Impact on the Environment

1. What do you consider to be your most significant Environmental Aspect and Impacts? (Largest pollution impact on the Earth; coming from what process of your business). Example: Air pollution coming from heating ovens during the paint curing process or Air pollution due to energy usage to cool our buildings. Please be specific.

*Third Party = an audit performed by someone in your facility or parent company or by an independent auditor, but not by individuals who played a substantive role in developing the EMS for the facility. A third party audit must be conducted, at a minimum every three years for the ELP.

1. Date of your last third-party audit of your EMS? Date:

2. Who performed the third party audit (name and company)?

3. How often are your third-party audits scheduled?

Section 5 – Annual Environmental, Sustainable and Community/Social Goals, metrics and results Please report on your past year’s environmental metrics. (Just one year of information please). Gold Leaders are required to have at least four completed goals with supporting metrics. (Small businesses with 50 employees or less are required to have at least two).

1. What is the reporting year for your metrics? (Reporting should be for 2016 and/or 2016/2017 depending on how your reporting calendar year ends).      

2. What reporting year do you follow * Calendar Year (Jan 1 - Dec31) Federal Fiscal Year (Oct 1 – Sept 30) State Fiscal Year (July 1 – June 30) Other:      

The next seven (7) questions align with our EPA grant that provides financial support for the ELP Program. We realize that your company may not have set goals for these particular metrics, however if you have these metrics, please complete the following questions for your past year’s information. If not, leave the question(s) blank.

1. Annual Water Savings (gallons) Gallons Saved:       Describe the activities implemented resulting in water savings (e.g., irrigation audit, xeriscaping, fixture

replacements, fixed leaks, etc.):      

2. Annual Hazardous substances reduced. Reductions in pounds of hazardous inputs and hazardous pollutants released to air, water and land in gallons or pounds. Gallons:       Pounds (lbs):       Please describe how the reductions were accomplished:

o Source Reduction; (eliminating or reducing the use of a product, therefore reducing the waste):      

o Landfill Diversion; (this includes treatment, recycling or reuse of a product or material – in this case, please indicate how the waste was either treated, recycled or reused):     

3. Annual Renewable Energy Produced or purchased Kilowatt hours (kWh) produced:       Please describe activities implemented to produce or purchase renewable energy (ie purchased onsite

solar, subscription to solar garden, purchased wind source energy, etc.):      

4. Annual Electricity Use Savings

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Kilowatt hours (kWh) reduced:       Please describe activities implemented to reduce electricity usage (e.g., lighting retrofit, HVAC Controls,

building retro-commissioning, etc.):      

5. Annual Natural Gas Savings (Please report using MMBtu as the units. Conversion Factor: 1 MMBtu = One million Btu = 10 therms) Natural gas (MMBtu) saved:       Please describe activities implemented to reduce natural gas usage (e.g., installed programmable

thermostat in warehouse, etc.):      

6. Annual Amount Recycled Pounds (lbs) recycled:       Please describe your recycling efforts including type of product recycled and measured improvements

(increases in amount recycled from year to year). Please provide weights or material recycled. For businesses in the recycling industry, please list recycling generated internally separate from what is hauled or managed as a service to others.      

7. Annual Amount Composted Pounds (lbs) composted:       Please describe activities implemented to increase composting (e.g., composting paper towels, etc.):

Any additional goals and metrics that your company has identified, but are not included in the first seven metric questions. Please only include metrics for the past year.

1. Please list Goal 1:       Activities Implemented to Meet Goal 1:       Results of Goal 1:      

2. Please list Goal 2:       Activities Implemented to Meet Goal 2:       Results of Goal 2:      

3. Please list Goal 3:       Activities Implemented to Meet Goal 3:       Results of Goal 3:      

4. Please list Goal 4:       Activities Implemented to Meet Goal 4:       Results of Goal 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:

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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:

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.

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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. 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:

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Section 6 - Additional Information

1. Please describe how your environmental goals are shared with employees and customers.

2. Does your organization produce a regular, public report that includes or entirely focuses on environmental and/or sustainability goals and achievements? Yes No

If yes, what type of report: Corporate Social Responsibility Report (CSR) Sustainability Report Global Reporting Initiative (GRI) Other: Please include a report copy or website link:

Please send and electronic copy of the following with this application: This ELP Application Section 2: Company description for website (if choosing to send as an attachment) Section 3: Two pictures which represent your company Section 3: Your company logo (if it has changed in the past year) Section 6: Environmental/Sustainability Report if applicable Section 7: Signed/scanned copy of the Application and Participation Statement (last page)

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Section 7 - 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 implemented and/or is in the process of implementing an environmental management system (EMS), as defined in The Colorado Environmental Leadership Program Handbook 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 the state’s decision whether to accept participants into or remove them from the Gold Leader 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)

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