VERMONT BUSINESS ENVIRONMENTAL PARTNERSHIP ACHIEVEMENT FORM
This form should be completed and signed to document the steps taken by the participating business to achieve program designation. The information also will be used to help publicize efforts undertaken at the business. Please submit the completed form to: VERMONT BUSINESS ENVIRONMENTAL PARTNERSHIP, c/o Vt SBDC, PO Box 188, Randolph Ctr., VT 05061. For answers to any questions you may have about this Achievement Form, call the Vermont Small Business Development Center at (802) 728-1423, or e-mail pcrawford@vtc.edu BUSINESS NAME: MAILING ADDRESS: EMAIL: WEBSITE: PROGRAM CONTACT: PHONE: DATE SUBMITTED: I certify that has either met the standards or intends to implement the standards below as documented in this Achievement Form. By signing this statement, I am agreeing to implement the new initiatives listed on this form within a reasonable timeframe. I agree to ensure the standards are met for at least a period of three years from the submission date. I also agree to complete and return the annual Partner Performance Survey, and continue to make a good faith effort to comply with all state and federal environmental regulations.
Signature of Owner/General Manager
Date
____________________________________
Owner/General Manager (please print)
STANDARDS FOR
ENVIRONMENTAL PARTNER
Businesses receiving the ENVIRONMENTAL PARTNER designation must meet all of the standards below. New initiatives are strongly encouraged for fulfilling these standards whenever possible, though businesses will be credited for some recent or existing initiatives. 1. An Environmental Policy statement has been adopted, posted and communicated
Date Policy Adopted (Attach Copy of Policy):
ENVIRONMENTAL PARTNER
STANDARDS (Continued)
2. An Environmental Representative (or Team) has been designated to ensure these standards are met at our business.
Representative’s Name:
Phone/Extension:
3. An environmental assessment has been performed by VT-SBDC or VT-DEC
Date Performed (or scheduled date): Performed by:
4. We have eliminated or reduced one form of hazardous or solid waste, wastewater discharge or an air emission. Describe:
QUANTIFY:
5. We have implemented the following energy efficiency measures: Approx. KWH Savings: 6a. We have reused or recycled three forms of solid or hazardous waste. Describe waste and method:
Waste 1: Waste 2: Waste 3:
Quantity per week/mo.: Quantity per week/mo.: Quantity per week/mo.:
6b. We purchase for use or resale, at least three (3) products which satisfy any of the following: contain Post Consumer (PC%) recycled content; or substantially reduce packaging waste; or that are non-toxic or less toxic alternatives to chemical supplies previously purchased, with the PC % if applicable.
Product: Product: Product: Used Used Used resold resold resold reduced pkg. reduced pkg. reduced pkg. less toxic less toxic less toxic PC%: PC%: PC%:
We have developed an Environmentally Preferable Purchasing Policy, attached
ENVIRONMENTAL PARTNER
STANDARDS (Continued)
7. We have made a commitment to promote the Vermont Business Environmental Partnership by either
referring another company to the Partnership or by marketing the Partnership through your own marketing efforts.
8. Pollution Prevention Best Management Practices (choose at least one):
We have created incentives for ride-sharing or institute a new product/service delivery system in order to reduce vehicle miles traveled by employees and/or customers. Describe: We have adopted and practice grounds keeping/landscaping methods that achieve resource conservation. Describe: We have participated in environmental training(s), include environmental issues in our regular employee trainings or have created an employee incentive to improve environmental management at our facility. We contribute to a community environmental project that promotes stewardship of the environment. Describe Project(s): We have implemented one method to notify customers, and/or the community at large about our efforts to improve environmental management at our business. Describe: We have implemented other environmental best management or green building practices: We have taken the following additional steps to reduce our Carbon Footprint/Greenhouse Gas Emissions: Biodiesel for vehicles or heating Heating system efficiency improvements that create emission reductions Installing renewable energy sources (solar hot water, photovoltaics, biomass or windpower) Purchasing renewable energy credits: Significant product local sourcing for:
OTHER:
For answers to any questions you may have about completing this form please call the VT-SBDC at 802728-1423 or the Environmental Assistance Office at (802) 241-3487. Please feel free to include whatever supplementary materials to this Achievement Form that might make the task of review more meaningful NOTE: The Vermont Business Environmental Partnership and Green Hotels program are open to all Vermont businesses, lodging properties, manufacturers and service providers.