Vermont Business Environmental Partnership

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

BUSINESS NAME:

MAILING ADDRESS:

WEBSITE:

PROGRAM CONTACT:

PHONE:

EMAIL:

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. Required boxes are checked for you.

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: Quantity per week/mo.: ?

Waste 2: Quantity per week/mo.: ?

Waste 3: Quantity per week/mo.: ?

Guest Access to Recycling, attach what you use to communicate to guests what can be recycled and how they can do this.

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: Used resold reduced pkg. less toxic 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, or encourage telecommuting.

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):

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, or low emission fleet vehicles

Heating system efficiency improvements that create emission reductions

Installing renewable energy sources (solar hot water, photovoltaics, biomass or windpower)

Purchase of renewable energy:

Significant product local sourcing for:

OTHER:

For answers to any questions you may have about completing this form please call the VT-SBDC at 802-728-1423 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.