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

(If name has changed within past 2 years)



Site/Facility Address


Primary Contact for your ESI Membership


Secondary Contact


Site/Facility Management



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

Multi-site applications are only allowed for Partners.


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.

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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.

Has the site completed implementation of an EMS but not become 3rd party certified?
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Is the site planning to get certified to ISO 14001?

Noncompliance

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

(Objective - include any numerical target associated with units as well as baseline and timeframe)

(list projects implemented or planned and any outcomes achieved)

(Objective - include any numerical target associated with units as well as baseline and timeframe)

(list projects implemented or planned and any outcomes achieved)

(Objective - include any numerical target associated with units as well as baseline and timeframe)

(list projects implemented or planned and any outcomes achieved)

(Objective - include any numerical target associated with units as well as baseline and timeframe)

(list projects implemented or planned and any outcomes achieved)

(Objective - include any numerical target associated with units as well as baseline and timeframe)

(list projects implemented or planned and any outcomes achieved)



Certification Statement

By submitting this application, the certifying official below acknowledges that participation in this program is entirely voluntary and that the information provided in this application is truthful to the best of his/her knowledge.


The certifying official agrees to report annual progress toward the site’s environmental performance goals, reductions in environmental emissions or discharges, solid and hazardous waste disposal, use of energy and water, and any reportable non-compliance events.


This annual report must cover the scope of the organization represented in the application.


The certifying official agrees to implement an EMS based on ISO 14001 or a functionally equivalent model and/or to report on at least two measurable environmental goals.


The undersigned accepts and hereby waives any right to appeal any decision made by the N.C. Department of Environmental Quality regarding participation in, or termination from, this program.

Highest management representative at facility


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