NW ENERGY MANAGEMENT SYSTEMS PILOT APPLICATION FORM by dbn14335

VIEWS: 5 PAGES: 3

									1.   IS PARTICIPATING FACILITY A SINGLE ENTITY OR PART OF A MULTI-FACILITY ENTERPRISE?
     ORGANIZATION NAME:
     CORPORATE ADDRESS (STREET, CITY, STATE, ZIP):
     NUMBER OF FACILITIES:
     PARTICIPATING FACILITY NAME:

     FACILITY ADDRESS (STREET, CITY, STATE, ZIP):

2.   DESCRIBE YOUR FACILITY
     INDUSTRY SECTOR AND PRIMARY PRODUCT LINES:

     SIZE (NUMBER OF EMPLOYEES):
     APPROXIMATE ANNUAL ENERGY EXPENDITURES (AS A PERCENTAGE OF OPERATING EXPENSES):  electricity                                     % |  natural gas   % |  fuel oil   % |  other   %

3.   DOES YOUR ORGANIZATION CURRENTLY HAVE THE FOLLOWING?
     a. Energy management goals?  yes  no         If so, briefly describe:


     b. Framework to track progress toward goals?  yes  no         If so, briefly describe:


     c. Key performance indicators (KPI’s) for energy, quality, or productivity?  yes  no          If so, briefly describe:


     d. An energy team?  yes  no           If so, for how long?                                yrs/mos
     e. Experience with ISO standards?     yes  no      If so, briefly describe:




4.   WHAT ARE SOME BENEFITS YOUR FACILITY WISHES TO REALIZE THROUGH PARTICIPATION IN THE NORTHWEST ENERGY MANAGEMENT SYSTEM PILOT? NUMBER THE BOXES
     BEGINNING WITH ’1’ AS THE MOST VALUABLE BENEFIT.
          a. Energy management system                                                f. Improve energy projects ROI
          b. Competitive advantage through energy management                         g. Improve operations and maintenance
          c. Control energy costs                                                    h. Record of energy savings and carbon emission reductions
          d. Decrease energy intensity                                               i. Other:
          e. Prepare for ISO
NORTHWEST ENERGY MANAGEMENT SYSTEM PILOT RACI MATRIX
RACI REPRESENTS:                       RACI DEFINIT IONS:
R – RESPONSIBILITY                     RESPONSIBILITY - person or role responsible for actually doing or completing the item
A – ACCOUNT ABLE                       ACCOUNTABLE   - person or role responsible for ensuring that the item is completed
C – CONSULTED                          CONSULTED - person or role whose subject matter expertise is required in order to complete the it em
I – INFORMED                           INFORMED - person or role that needs to be kept informed of the status of item completion

Simply place an R, A, C, I or any appropriate combination in each of the applicable roles for each activity. Each activity should have at least one indi vidual accountable while there may be shared
responsibilities depending on the activity.

                                                                           ROLE     SENIOR MANAGEMENT          LEAD PROJECT MANAGER           PROJECT TEAM MEMBERS         OFFSITE: CORPORATE
                                                                                    SPONSOR                                                                                HEADQUARTERS
                                                                     Name, Title
                                                                             Ph:
                                                                              Fx:
                                                                          E-mail:

   PROJECT DELIVERABLE (OR ACTIVITY)
 Initiation Phase
 Create project budget that includes travel and training
 Planning Phase
 Manage energy bill data
 Attend 3 two-and-a-half day workshops
 Execution Phase
 Manage energy purchasing
 Approve capital expenditures under 25,000.00
 Approve capital expenditures over 25,000.00
 Approve O & M supplies and expenses
 Specify operating policies & practices regarding high-intensity energy systems:
     steam
     process heating
     compressed air
     pumps
 Conclusion Phase
 Successful outcome of pilot project
6. AN IMPORTANT ELEMENT OF THE NORTHWEST ENERGY MANAGEMENT SYSTEM PILOT IS REPORTING ON THE CHALLENGES AND SUCCESSES OF PARTICIPATING FACILITIES.
   PROPRIETARY INFORMATION WILL BE PROTECTED. ANY CASE STUDY ON YOUR FACILITY’S PARTICIPATION IN THE PROJECT WILL BE APPROVED BY YOUR SITE BEFORE RELEASE.
       Is your site willing to participate in case study reporting?  yes  no
       If not, please indicate why:


7   SENIOR MANAGEMENT SPONSOR
    ONGOING SUPPORT FROM TOP MANAGEMENT IS VITAL FOR SUCCESSFUL, SUSTAINABLE ENERGY MANAGEMENT.

    a. Is your facility willing to commit to obtaining certification under ISO 50001?    yes  no

    b. Is your facility willing to commit to an energy intensity reduction goal of at least 3% over 3 years?    yes  no

    c. Briefly describe your commitment to ensuring pilot project visibility and value throughout facility.




    d. Briefly describe your commitment to directing staff time & involvement to the pilot project.




    SENIOR MANAGEMENT SPONSOR



Signature                                                                 Date                                                                           V. 1

								
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