New Partner Application

New Partner Application

All information provided in the application is considered public information. If there are confidentiality issues please contact an ESI team member at 1-877-623-6748 or esi@ncdenr.gov

Please provide the general information about the facility as indicated on this page. If this application is for multiple sites, be sure to provide names and addresses for each site to be included in the program.

Multi-site applications are only accepted at the Partner level. Multi-site partners only need to submit a single annual report that includes information from all sites joining the program from a single organization/corporation. If one of those sites meets the requirements for the higher levels and would like to apply to that level separately, it is allowed and encouraged. However, that site would then be required to report separately on its individual progress.

General Information

Organization Name*

Previous Name

(If name has changed within past 2 years)

NAICS Code

Products or Services Provided by Your Organization

Number of Employees

Site/Facility Address

Street Address*

City*

Zip Code*

County*

Facility's Main Phone Number

Check box below if your mailing address is different than listed above

Mail Address

Mail City

Mail Zip Code

Primary Contact for your ESI Membership

Contact Name*

Contact Title

Contact Email*

Contact Phone Number*

Secondary Contact

Secondary Name

Secondary Title

Secondary Email

Secondary Phone

Site/Facility Management

Manager Name

Manager Title

Manager Email

Manager Phone

Number of Paid Environmental Staff

Facility or Corporate Website

Check box below if this application involves multiple sites

For multi-site applications, enter a site name and address for each location to be included.

Multi-site applications are only allowed for Partners.

Site 2 Name

Site 2 Address

Site 3 Name

Site 3 Address

Additional Sites

Permit Information

Please list any environmental permits and regulatory requirements, including permit numbers and/or ID numbers (i.e. hazardous waste identification numbers, etc). A pull-down menu is provided for most state permits. For those local, federal or state permits not listed, or if you need additional lines, use the extra lines at the bottom of the table.

Permit 1

Select

Permit/ID Number 1

Permit 2

Select

Permit/ID Number 2

Permit 3

Select

Permit/ID Number 3

Additional Permits

EMS Information

Please tell us about the facility's environmental management system or plans to implement one.

Partners are not required to implement an EMS as long as they report on at least 2 measurable environmental goals.

Check box if this site is certified to ISO 14001

Date of Initial Certification

3rd Party Registrar

Frequency of 3rd Party Audits

Date of Last Surveillance Audit

Certificate Expiration Date

Has the site completed implementation of an EMS but not become 3rd party certified?

Yes

What EMS model was used?

Select

Please Specify Other EMS

Is the site planning to get certified to ISO 14001?

Yes

Noncompliance

Have you had a regulatory noncompliance in the last 5 years?*

Yes

Describe Noncompliance*

Root cause of noncompliance:*

Method of Root Cause*

Select

Other Root Cause*

Date Reported*

NOV or other action?*

What action(s) was/were taken to prevent reoccurrence?*

(ex. Corrective action plan, updated protocols)

Goals

Tell us about your environmental goals for the upcoming year. Space for 5 goals is provided, but it is not required or expected that your organization will have that many goals. A minimum of 2 measurable goals is required unless the site is in the process of implementing an EMS. If EMS implementation is the goal, it is the only one required.

Use SMART goals whenever possible:

S - Specific

M - Measurable

A - Attainable

R - Relevant

T - Time-Bound

Goal 1*