ATTACHMENT A: GEMS PERMIT APPLICATION – GENERAL INSTRUCTIONS AND SAMPLE FORM
This attachment contains the following sections:  
•	General Instructions for Green Permit Applications
•	GEMS Permit Application Form
•	Custom Waiver Permit Application Form
•	Sample GEMS Application (Acme Manufacturing example)
General Instructions

The Oregon Green Permit application forms should be completed using these instructions, the Green Permit Program Guide, and the GEMS or Custom Waiver Permit Criteria for Permit Approval worksheets.  Details about specific permits are contained in the Green Permit Program Guide.  Where requirements differ among permits, specific instructions are included.  
The completed Green Permit application form will provide the Department with an idea of how much effort is needed to issue a GEMS or Custom Waiver Permit.  Providing a more detailed application will make it easier for the Department to issue the permit and reduce recovery costs. 
The completed application will be made available to the EPA, other agencies, and the public for review.  
•	Land Use Compatibility Statement
A Land Use Compatibility Statement (LUCS) must be submitted with the Green Permit application.  If the facility already has submitted a LUCS to the Department for another permit, a new LUCS may not be needed.  A previously dated LUCS that has not been submitted to the Department is adequate unless a modification has taken place.  A new LUCS is required if the GEMS or Custom Waiver Permit application contains any of the following proposed modifications:  
•	The permitted source or activity relates to the use of additional property or a physical expansion on the existing property.  The LUCS applies to physical changes on the property, rather than existing permit conditions;
•	The permitted source or activity involves a significant increase in discharge to state waters or into the ground;
•	The permitted source or activity involves the relocation of an outfall outside of the source property; or
•	The permitted source has applied for a major modification of an air contaminant discharge permit, which means any physical change or change of operation of a source that results in a net significant emission rate increase as defined in OAR 340-020-0225(25).
•	Electronic Submission
The Green Permit application and all attachments must be submitted in hard copy and electronic format.  The application must be submitted in Microsoft Word or other software that is easily converted to Microsoft Word.  If an electronic version of an attachment is not readily available, then the application should state how to readily obtain a copy of the attachment.  The application will be placed on DEQ’s web site to improve public access to information about the Green Permits program.  
•	Submitting the Green Permit Application to the Agency
The application submittal to the Department should include the following:  
•	two hard copies of all applicable forms and associated attachments
•	high-density or double-density computer disks containing electronic versions of the completed answer sheets and attachments, or an e-mail containing the electronic versions
•	a check for $5,000 made out to the Oregon Department of Environmental Quality
The application should be submitted to the Department of Environmental Quality, attention:  Marianne Fitzgerald, 811 SW 6th Avenue, Portland, OR, 97204.  For more information, phone (503) 229-5946, fax (503) 229-5850, or email fitzgerald.marianne@deq.state.or.us.  
Facilities in Lane County may apply to the Lane Regional Air Pollution Authority if their environmental impacts include air issues.  
•	Information Exempt from Disclosure 
The Department handles requests for exemption from public disclosure in accordance with Oregon Revised Statutes (ORS) 192.410 to 192.505, the Public Records Law, and ORS 646.461 to 646.475, the Uniform Trade Secrets Act.  These two statutes are interpreted in the Attorney General's Public Records and Meetings Manual as follows.  ". . . records withheld from disclosure under this exemption must meet all of the following criteria:
•	The information must not be patented;
•	It must be known only to a limited number of individuals within a commercial concern who have made efforts to maintain the secrecy of the information;
•	It must be information that derives actual or potential economic value from not being disclosed to other persons; and
•	It must give users the chance to obtain a business advantage over competitors lacking the information."
A request for an exemption from disclosure must include an explanation of the statutory basis for exemption.  If more than one statute applies, the request must clearly specify the information that is claimed exempt under each statute.
Each page containing material proposed to be exempt must be clearly marked.  If possible, submittals should be arranged so that non-exempt and proposed exempt materials are on separate pages; if a page contains both non-exempt and proposed exempt material, the two must be clearly distinguishable.  Any information not clearly identified as exempt will be treated as public information.
•	Alternative Formats
Applicants are encouraged to design their own application using a different format than suggested here, and incorporating text, charts and graphs.  Applications must be available and easy to download electronically and meet basic information requirements.  

Gems Permit Application Form
1.	Facility Name/Site Identifier		
	(Include a site identifier if the corporation has more than one site by the same name in Oregon.)
2.	Legal name as registered with the Oregon Corporations Division (if the same as above, enter "same")

3.	Mailing address
a.	PO box or street number		
b.	city, state, and zip code		
4.	Facility location address (if the same as above, enter "same”)
a.	PO box or street number		
(if the facility is not located on a street, provide other directional information such as nearby cross streets or an industrial park name, if appropriate)
b.	city, state, and zip code		
(if the facility is not located within an incorporated city, write “unincorporated”)
c.	county		
5.	Contact information
a.	name and title		
b.	area code and telephone number		
c.	mailing address		
	(if the same as above, write “same”)
6.	Business activity information
a.	primary NAICS Code ________________  or SIC  Code _____________
(Enter the North American Industry Classification System (NAICS) Code for this facility as registered with the Secretary of State of the State of Oregon (e.g., 321113 for sawmill).  The NAICS codes replace Standard Industrial Classification (SIC) codes.  If the NAICS Code is not available, enter the SIC code of this facility. (e.g., 2421 for sawmill).)
b.	facility description (briefly describe the facility (e.g., "sawmill," "printed circuit board manufacturer"))

7.	Current regulatory status.  Include permit numbers for any programs that require permits.  If you do not know the current status, check the DK (don’t know) box.  Please note any outstanding compliance issues, such as a pending or enforcement action or any ongoing permit issues.

Regulatory Status Category 	Permit Number (if issued)	Permitting or Compliance Issues	
RCRA:  Is your facility	
A Large Quantity Generator?	Y  N  DK			
A Small Quantity Generator?	Y  N  DK			
A Conditionally Exempt Generator?	Y  N  DK			
A TSD Facility?	Y  N  DK			
AIR:  Is your facility	
Permitted under a state or local ACDP?	Y  N  DK			
Permitted under a Title V permit?	Y  N  DK			
Not required to have a permit?	Y  N  DK			
WATER:  Is your facility	
Permitted under a state WPCF permit?	Y  N  DK 			
Required to pretreat by the local POTW (federal requirements)?	Y  N  DK 			
Permitted under a POTW industrial discharger permit?	Y  N  DK 			
Permitted under an NPDES wastewater permit?	Y  N  DK 			
Permitted under an individual storm water permit?	Y  N  DK 			
Permitted under a general storm water permit?	Y  N  DK 			
Regulated under the Underground Injection Control Program?	Y  N  DK 			
Not required to have a permit?	Y  N  DK 			
OTHER:  Is your facility	
Required to have a Solid Waste Permit?	Y  N  DK 			
A TRI reporter?	Y  N  DK 			
A State Fire Marshal Hazardous Substance reporter?	Y  N  DK			
A potentially responsible party under the federal Superfund program?	Y  N  DK 			
Participating in Oregon’s Voluntary Cleanup program?	Y  N  DK 			
Regulated under the Safe Drinking Water Act?	Y  N  DK 			
Subject to Underground Storage Tank Regulations?	Y  N  DK 			
Regulated under TSCA?	Y  N  DK 			
Required to have a SPCC Plan?	Y  N  DK 			
Regulated under FIFRA?	Y  N  DK 			
Other?			Y  N  DK 			
Other?			Y  N  DK 			
8.	
Implementation status of your Environmental Management System (EMS) (check the appropriate boxes or provide dates indicating when portion of your EMS was implemented and began functioning): 
	 Not yet developed    
	 Basic EMS    
	 ISO Comparable EMS     
	 ISO Certified EMS    		Date Certified:  ___________________________________
	Third Party Certified		Certified by:  ____________________________________

EMS Element	In Development	Functioning Since (date)	
Environmental Policy Statement			
Identification of Environmental Aspects and Impacts			
Setting Objectives and Targets			
Structure and Responsibility			
Training			
External Communications			
Monitoring and Measurement			
EMS Audits			
Management Review			
Certification			
Please attach a copy of your environmental policy (either facility or corporate) to this application.  
9.	Significant environmental impacts.   Complete the table on the following page.  If impacts do not lend themselves to numerical values, please provide a written summary.  Include additional pages if necessary.  An illustrative example follows.
a.	A significant environmental impact could be VOC emissions to the air.  
b.	The associated performance measure is tons VOC/year as an annual rate; a normalization factor would be tons VOC/unit production.  
c.	Current levels would be the facility’s baseline performance.  The baseline is the calendar year preceding the year in which the permit is applied, or other 12-month period approved by the agency.  
d.	Past performance is the level during the three-year period prior to the facility’s baseline performance.  Past performance levels for different significant environmental impacts are not required to occur in the same year.  
e.	The regulatory limit could be a Reasonably Available Control Technology (RACT) for VOC such as 3.5 lbs./gallon.  In many cases, your facility’s significant environmental impact may have no regulatory limit, such as the amount of solid waste generated.  
f.	The future target/objective could be a 20% reduction, or 5 tons/year of 1.5 lbs/gallon.
a.	
9.	(continued) [Note: Only GEMS Achiever and Leader applicants are required to report past performance and address unregulated pollutants/impacts.]
Regulated or Other Significant Environmental Impacts	Regulatory Limit  (if any)	Performance Measure/ Normalization Factor	Current Levels (baseline)	Past Performance	Future Target/ Objective	
		a.	annual rate
b.	unit rate	a.	annual rate
b.	unit rate	a.	annual rate
b.	unit rate		
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[NOTE: ANSWERS TO QUESTIONS 9, 10 AND 11 MAY BE ANSWERED USING  A DIFFERENT FORMAT THAN THE TABLE IN THIS FORM, AS LONG AS THE PERFORMANCE INFORMATION OVER TIME CAN BE CLEARLY INTERPRETED BY THE READER.]

10.	Performance Improvements.  If not demonstrated in the table above, how has the facility’s performance improved over the past three years?

11.	Superior Environmental Performance.  How will environmental performance be significantly better than otherwise be required by law? 

12.	Performance Reporting Plan. Please describe the data elements and other information the facility will include in its future annual performance reports.    

13.	Stakeholder Involvement Plan.  Please describe the proposed process for reporting to and for involving stakeholders and citizens, including identifying your key stakeholders who will have an interest in the EMS and environmental performance of your facility.  Include current activities and proposed elements of the Stakeholder Involvement plan.  (Note: Stakeholder involvement requirements vary for different types of Green Permits.  Please refer to the Green Permits Program Guide for more information.)

14.	Desired incentives or waivers.  Describe the requested waivers and incentives and justification for receiving them.  (Note: Available incentives vary for different types of Green Permits.  Please refer to the Green Permits Program Guide for more information.)

15.	
Statement of Certification
The person at the facility responsible for implementing the environmental management system, i.e. the facility manager, should sign the following statement.  He/she should be able to verify the truth, accuracy and completeness of the contents of this application.  The name and title of the designated official and the date below may be handwritten or typed.  However, the signature must be handwritten and original.
I have reviewed this application and all supporting documentation in their entirety and to the best of my knowledge, information, and belief formed after reasonable inquiry, the statements and information contained herein are true, accurate, and complete.

Name of designated responsible official:		
Title of responsible official:		

                                                                                                                                                        
Signature of responsible official					        Date 

Custom Waiver Permit Application Form
1.	Facility Name/Site Identifier		
	(Include a site identifier if the corporation has more than one site by the same name in Oregon.)
2.	Legal name as registered with the Oregon Corporations Division (if the same as above, enter "same")

3.	Mailing address
a.	PO box or street number		
b.	city, state, and zip code		
4.	Facility location address (if the same as above, enter "same”)
a.	PO box or street number		
(if the facility is not located on a street, provide other directional information such as nearby cross streets or an industrial park name, if appropriate)
b.	city, state, and zip code		
(if the facility is not located within an incorporated city, write “unincorporated”)
c.	county		
5.	Contact information
a.	name and title		
b.	area code and telephone number		
c.	mailing address		
	(if the same as above, write “same”)
6.	Business activity information
a.	primary NAICS Code ________________  or SIC  Code _____________
(Enter the North American Industry Classification System (NAICS) Code for this facility as registered with the Secretary of State of the State of Oregon (e.g., 321113 for sawmill).  The NAICS codes replace Standard Industrial Classification (SIC) codes.  If the NAICS Code is not available, enter the SIC code of this facility. (e.g., 2421 for sawmill).)
b.	facility description (briefly describe the facility (e.g., "sawmill," "printed circuit board manufacturer"))

7.	Current regulatory status.  Include permit numbers for any programs that require permits.  If you do not know the current status, check the DK (don’t know) box.  Please note any outstanding compliance issues, such as a pending or enforcement action or any ongoing permit issues.

Regulatory Status Category 	Permit Number (if issued)	Permitting or Compliance Issues	
RCRA:  Is your facility	
A Large Quantity Generator?	Y  N  DK			
A Small Quantity Generator?	Y  N  DK			
A Conditionally Exempt Generator?	Y  N  DK			
A TSD Facility?	Y  N  DK			
AIR:  Is your facility	
Permitted under a state or local ACDP?	Y  N  DK			
Permitted under a Title V permit?	Y  N  DK			
Not required to have a permit?	Y  N  DK			
WATER:  Is your facility	
Permitted under a state WPCF permit?	Y  N  DK 			
Required to pretreat by the local POTW (federal requirements)?	Y  N  DK 			
Permitted under a POTW industrial discharger permit?	Y  N  DK 			
Permitted under an NPDES wastewater permit?	Y  N  DK 			
Permitted under an individual storm water permit?	Y  N  DK 			
Permitted under a general storm water permit?	Y  N  DK 			
Regulated under the Underground Injection Control Program?	Y  N  DK 			
Not required to have a permit?	Y  N  DK 			
OTHER:  Is your facility	
Required to have a Solid Waste Permit?	Y  N  DK 			
A TRI reporter?	Y  N  DK 			
A State Fire Marshal Hazardous Substance reporter?	Y  N  DK			
A potentially responsible party under the federal Superfund program?	Y  N  DK 			
Participating in Oregon’s Voluntary Cleanup program?	Y  N  DK 			
Regulated under the Safe Drinking Water Act?	Y  N  DK 			
Subject to Underground Storage Tank Regulations?	Y  N  DK 			
Regulated under TSCA?	Y  N  DK 			
Required to have a SPCC Plan?	Y  N  DK 			
Regulated under FIFRA?	Y  N  DK 			
Other?			Y  N  DK 			
Other?			Y  N  DK 			

8.	Environmental Performance.   Complete the table on the following page regarding environmental impacts at the facility that are affected by the proposed waiver.  You may provide additional information regarding other environmental impacts at the facility.  If impacts do not lend themselves to numerical values, please provide a written summary.  Include additional pages if necessary.  An illustrative example follows.
g.	An environmental impact could be VOC emissions to the air.  
h.	The associated performance measure is tons VOC/year as an annual rate; a normalization factor would be tons VOC/unit of production.  
i.	Current levels would be the facility’s baseline performance.  The baseline is the calendar year preceding the year in which the permit is applied, or other 12-month period approved by the agency.  
j.	Past performance is the level during the three-year period prior to the facility’s baseline performance.  Past performance levels for different significant environmental impacts are not required to occur in the same year.  
k.	The regulatory limit could be a Reasonably Available Control Technology (RACT) for VOC such as 3.5 lbs./gallon.  In many cases, your facility’s significant environmental impact may have no regulatory limit, such as the amount of solid waste generated.  
l.	The future target/objective could be a 20% reduction, or 5 tons/year of 1.5 lbs/gallon.
a.	
8.	(continued)
Regulated or Other Significant Environmental Impacts	Regulatory Limit  (if any)	Performance Measure/ Normalization Factor	Current Levels (baseline)	Past Performance	Future Target/ Objective	
		a.	annual rate
b.	unit rate	a.	annual rate
b.	unit rate	a.	annual rate
b.	unit rate		
		a.	annual rate
b.	unit rate	a.	annual rate
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[NOTE: ANSWERS TO QUESTIONS 8, 9, AND10 MAY BE ANSWERED USING A DIFFERENT FORMAT THAN THE TABLE IN THIS FORM, AS LONG AS THE PERFORMANCE INFORMATION OVER TIME CAN BE CLEARLY INTERPRETED BY THE READER.]

9.	Performance Improvements. How will the proposed waiver improve the facility’s performance?  How long will it take to achieve the future objective/targets?  How will the facility monitor and assess improvements to environmental performance?  

10.	Superior Environmental Performance.  How will environmental performance be significantly better than otherwise be required by law? 

11.	Performance Reporting Plan. Please describe the data elements and other information the facility will include in its future annual performance reports.    

12.	Stakeholder Involvement Plan.  Please describe the proposed process for reporting to and for involving stakeholders and citizens, including identifying your key stakeholders who will have an interest in the Custom Waiver and environmental performance of your facility.  Include current activities and proposed elements of the Stakeholder Involvement plan.  (Note: Stakeholder involvement requirements vary for different types of Green Permits.  Please refer to the Green Permits Program Guide for more information.)

13.	Desired waivers.  Describe the requested waivers and justification for receiving them. 

14.	
Statement of Certification
The person at the facility responsible for compliance with federal, state and local environmental regulations should sign the following statement.  He/she should be able to verify the truth, accuracy and completeness of the contents of this application and be responsible for ensuring that the proposed waiver will not result in negative environmental impacts.  The name and title of the designated official and the date below may be handwritten or typed.  However, the signature must be handwritten and original.
I have reviewed this application and all supporting documentation in their entirety and to the best of my knowledge, information, and belief formed after reasonable inquiry, the statements and information contained herein are true, accurate, and complete.

Name of designated responsible official:		
Title of responsible official:		

                                                                                                                                                        
Signature of responsible official					        Date 

Gems Permit Application Form - Sample Application
1.	Facility Name/Site Identifier:  Acme Paint Manufacturing	
	(Include a site identifier if the corporation has more than one site by the same name in Oregon.)
2.	Legal name as registered with the Oregon Corporations Division (if the same as above, enter "same")
same
3.	Mailing address
a.	PO box or street number:  12345 Main Street
b.	city, state, and zip code:  Portland, Oregon   97000
4.	Facility location address (if the same as above, enter "same”)
a.	PO box or street number:  same	
(if the facility is not located on a street, provide other directional information such as nearby cross streets or an industrial park name, if appropriate)
b.	city, state, and zip code:  	
(if the facility is not located within an incorporated city, write “unincorporated”)
c.	county:  Multnomah
5.	Contact information
a.	name and title:  Suzanne Wilson	
b.	area code and telephone number:  (503) 222-2222	
c.	mailing address:  same	
	(if the same as above, write “same”)
6.	Business activity information
a.	primary NAICS Code: 325510		  or SIC  Code _____________
(Enter the North American Industry Classification System (NAICS) Code for this facility as registered with the Secretary of State of the State of Oregon (e.g., 321113 for sawmill).  The NAICS codes replace Standard Industrial Classification (SIC) codes.  If the NAICS Code is not available, enter the SIC code of this facility. (e.g., 2421 for sawmill).)
b.	facility description (briefly describe the facility (e.g., "sawmill," "printed circuit board manufacturer")
Paint and Coating Manufacturing
7.	Current regulatory status.  Include permit numbers for any programs that require permits.  If you do not know the current status, check the DK (don’t know) box.  Please note any outstanding compliance issues, such as a pending or criminal enforcement action or any ongoing permit processes.
Regulatory Status Category 	Permit Number (if issued)	Permitting or Compliance Issues	
RCRA:  Is your facility	
A Large Quantity Generator?	Y  N  DK			
A Small Quantity Generator?	Y  N  DK		Hazardous waste TA visit in 1998.  All recommendations were implemented.  	
A Conditionally Exempt Generator?	Y  N  DK			
A TSD Facility?	Y  N  DK			
AIR:  Is your facility	
Permitted under a state ACDP?	Y  N  DK	26-1234	DEQ inspection on 4/4/99; no violations found.  	
Permitted under a Title V permit?	Y  N  DK			
Not required to have a permit?	Y  N  DK			
WATER:  Is your facility (check all that apply)	
Permitted under a state WPCF permit?	Y  N  DK 			
Required to pretreat by the local POTW (federal requirements)?	Y  N  DK 			
Permitted under a POTW permit?	Y  N  DK 	500	City issued a NON for a late monitoring report in February 1997; no problems since then.  	
Permitted under an NPDES wastewater permit?	Y  N  DK 			
Permitted under an individual storm water permit?	Y  N  DK 			
Permitted under a general storm water permit?	Y  N  DK 			
Regulated under the Underground Injection Control Program?	Y  N  DK 			
Not required to have a permit?	Y  N  DK 			
OTHER:  Is your facility (check all that apply)	
Required to have a Solid Waste Permit?	Y  N  DK 			
A TRI reporter?	Y  N  DK 			
A State Fire Marshal Hazardous Substance reporter?	Y  N  DK			
A potentially responsible party under Superfund?	Y  N  DK 			
Participating in state Voluntary Cleanup program?	Y  N  DK 			
Regulated under the Safe Drinking Water Act?	Y  N  DK 			
Subject to Underground Storage Tank Regulations?	Y  N  DK 			
Regulated under TSCA?	Y  N  DK 			
Required to have a SPCC Plan?	Y  N  DK 			
Regulated under FIFRA?	Y  N  DK 			
Other?			Y  N  DK 			
Other?			Y  N  DK 			
8.	Implementation status of your Environmental Management System (EMS) (check the appropriate boxes or provide dates indicating when portion of your EMS was implemented and began functioning): 
	 Not yet developed    
	 Basic EMS    
	 ISO Comparable EMS     
	 ISO Certified EMS    	Date Certified 		
	Third Party Certified	Certified by:  		

EMS Element	In Development	Functioning Since (date)	
Environmental Policy Statement		January 1999	
Identification of Environmental Aspects and Impacts		March 1999	
Setting Objectives and Targets		March 1999	
Structure and Responsibility		June 1999	
Training		September 1999	
External Communications		June 1999	
Monitoring and Measurement		June 1999	
EMS Audits	Scheduled for March 2000		
Management Review	Scheduled for June 2000		
Certification	n/a		
9.	Significant environmental impacts.   Complete the table on the following page.  If impacts do not lend themselves to numerical values, please provide a written summary.  Include additional pages if necessary.  An illustrative example follows.
m.	A significant environmental impact could be VOC emissions to the air.  
n.	The associated performance measure is tons VOC/year as an annual rate; a normalization factor would be tons VOC/unit production.  
o.	Current levels would be the facility’s baseline performance.  The baseline is the calendar year preceding the year in which the permit is applied, or other 12-month period approved by the agency.  
p.	Past performance is the level during the three-year period prior to your facility’s baseline performance.  Past performance levels for different significant environmental impacts are not required to occur in the same year.  
q.	The regulatory limit could be a Reasonably Available Control Technology (RACT) for VOC such as 3.5 lbs./gallon.  In many cases, your facility’s significant environmental impact may have no regulatory limit, such as the amount of solid waste generated.  
r.	The future target/objective could be a 20% reduction, or 5 tons/year of 1.5 lbs/gallon.
a.	
9.	(continued) [Note: Only GEMS Achiever and Leader applicants are required to report past performance and address unregulated pollutants/impacts.]
Significant Environmental Impacts	Regulatory Limit  (if any)	Performance Measure/ Normalization Factor	Current Levels (baseline = 1999)	Past Performance
(1996)	Future Target/ Objective	
Air Emissions (VOC)	40 tons/year	a.	1.25 annual rate
b. number of gallons of coatings manufactured per year to determine production ratio	a.	27 tons/year annual rate
b.	10.8 lb/gal/year unit rate	a.	36 tons/year 
b.	 18 lb/gal/year 	No longer need a permit (consistently performing at less than 10 tons/year)	
Hazardous Waste	None	a.		annual rate
b.	gallons per year 	a.	6000 lb/year 
b.	1.2 lb/gallon/year 	a.	 8400 lb/year 
b.	 2.1 lb/gal/year 	Conditionally exempt generator status (60% reduction)	
Solid Waste	None	a.		annual rate
b.	 gallons per year 	a.	8 tons/year annual rate
b.	 3.1 lb/gal/year 	a.	 12 tons/year 
b.	  6 lb/gal/year 	50% reduction	
		a.	annual rate
b.	unit rate	a.	annual rate
b.	unit rate	a.	annual rate
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[NOTE: ANSWERS TO QUESTIONS 9, 10 AND 11 MAY BE ANSWERED USING A DIFFERENT FORMAT THAN THE TABLE IN THIS FORM, AS LONG AS THE PERFORMANCE INFORMATION OVER TIME CAN BE CLEARLY INTERPRETED BY THE READER.]
9.	Performance Improvements.  If not demonstrated in the table above, how has the facility’s performance improved over the past three years?  
Acme updated its Toxics Use Reduction plan in 1996, and implemented several pollution prevention projects that have yielded results.  Changes in the formulation of three of our product lines, as well as aggressive efforts to use less material and generate less waste, have resulted in the improvements in the table above.  
10.	Superior Environmental Performance.  How will environmental performance be significantly better than otherwise be required by law? 
Our environmental management system is being implement in lieu of doing further toxics use reduction plan updates.  We are working with five of our customers on new product formulations that should result in reductions in air emissions and hazardous waste generated.  Acme-Portland has developed software to closely monitor the use of certain materials and generation of wastes and pollutants within our facility, as a pilot that may be expanded for use by other Acme facilities.  This effort has become part of our quality improvement system, and has merged environmental concerns with other process efficiency reports.  This new software and procedures will help Acme improve its operating efficiency and result in environmental improvements, but it is difficult to quantify exact numbers at this time. We are working toward a 60% reduction in baseline levels.  
11.	Performance Reporting Plan. Please describe the data elements and other information the facility will include in its future annual performance reports.    
Acme will update the date for each of its significant environmental impacts and compare actual progress to the objectives and targets.  Acme will explain this progress and revisions to the EMS that will be made for future improvements.  Acme will also report on any compliance issues discovered and corrected during the past year.  
12.	Stakeholder Involvement Plan.  Please describe the proposed process for reporting to and for involving stakeholders and citizens, including identifying your key stakeholders who will have an interest in the EMS and environmental performance of your facility.  Include current activities and proposed elements of the Stakeholder Involvement plan.  (Note: Stakeholder involvement requirements vary for different types of Green Permits.  Please refer to the Green Permits Program Guide for more information.)

We have outlined the following tasks for the coming year:  

Tasks	Completion Target:  	
1.  Work with Acme corporate public affairs staff to develop a public environmental report and plan to solicit, receive and respond to public comments.  Plan will include evaluation measures.  	Develop report outline and plan by April 1, 2000	

Tasks	Completion Target:  	
 2.  Develop public environmental report (based on data in the application form and on file with DEQ) that can be distributed both in hard copy form and through the Internet.  	Complete report by September 1, 2000	
 3.  Upgrade web site to include the facility’s environmental report, and include an e-mail response page for public comments.  	Upgrade website by August 1, 2000, and place information on the web by Sept. 1, 2000	
 4.  Place advertisement in the local newspaper inviting the community to view the web page or request a copy of the environmental report, and get involved in community panel.  	November 1, 2000	
 5.  Establish community advisory panel (CAP) to discuss issues of concern or interest to the community, and upcoming projects that affect the environment.  	December 1, 2000	
 6.  Survey CAP members and random sample of community to evaluate effectiveness of outreach, 	April 1, 2001	
 7.  Update plan to identify activities for next fiscal year	August 1, 2001	
 8.  Update environmental report and web page	October 1, 2001	
 9.  Submit annual report on stakeholder involvement program to DEQ	October 1, 2001	

13.	Desired incentives or waivers.  Describe the requested waivers and incentives and justification for receiving them.  (Note: Available incentives vary for different types of Green Permits.  Please refer to the Green Permits Program Guide for more information.)
Single Point of Contact
Acme would like a single point of contact (SPOC) within DEQ. Ideally, this contact would be very familiar with the operations at Acme, so that he or she could facilitate decisions on all environmental aspects of our facility, as well as any Green Permit program issues. This person would help identify, track and resolve any issues relating to environmental regulatory and program matters.  The single point of contact would consult with compliance staff from all environmental agency programs regarding the findings of any compliance inspection conducted, and would ensure that the appropriate response is provided to the facility as outlined in the enforcement discretion policy for Green Permit program participants. 
Consolidated Permit Reporting
Acme would like to combine all our environmental reporting into one annual report in a format that is supported by our database tracking system.  This proposed incentive would consolidate all regulatory reports submitted to DEQ into one report that accompanies the Green Permit annual report.  Acme would send copies of the annual reports to the DEQ single point of contact, who would distribute them within the Department as needed. The reports to be combined would include the following:
•	Air Contaminant Discharge Permit annual report
•	Resource Conservation and Recovery Act hazardous waste annual report
•	Toxics Use Reduction and Hazardous Waste Reduction annual report
If possible, we also would like to use this method to submit our wastewater permit reports to the city.  Any compliance report required by DEQ or other programs that cannot be included in the Green Permits annual report would be submitted to individual agencies in accordance with existing policies and procedures for reporting.  In addition, regulatory compliance issues that require immediate reporting under existing rules (reporting spills, for example) would be reported to the appropriate DEQ program when they occur. 
Public Recognition
As a member of the DEQ Green Permit program, Acme would like formal recognition for the accomplishments at its Portland facility.  We would like DEQ to take the lead in advertising the benefits of the Green Permit program and publicly recognizing the participation and commitment of Acme-Portland to the program.  Acme would like the right to recognize the Portland facility as a member of the program (such as use of the Green Permit logo) by means of direct advertising.  We will help DEQ develop case studies to tell our story to the public.  
Tailored Enforcement Response 
Acme requests that DEQ and all other environmental agencies on the Green Permit team use enforcement discretion in carrying out facility inspections, as specified in DEQ guidance for Green Permits enforcement response.  The inspection response would focus on improvements to the environmental management system to achieve and maintain compliance.  Acme requests that they be provided time to correct administrative errors and compliance deficiencies that do not result in any detrimental environmental impacts.  This would include problems discovered through self-reporting or as the result of DEQ site visits.  Acme would utilize the corrective action process outlined in its EMS to correct these deficiencies in a timely manner, and will correct them in a way that will prevent such deficiencies in the future, and report on compliance issues and how they are resolved in our annual Green Permit report.  
Expedited Permit Applications
Acme would like the option of having our permit modifications/applications handled as a “high priority” at the state level.  Under this scenario, permit applications and modifications submitted to DEQ would be reviewed, processed and sent out for public notice within 90 days of receipt by DEQ.  
Flexible Permit/Exemption from Notice of Intent to Construct
Acme would like to see the “bubble” concept adopted for our facility regarding the permitted air emissions in its DEQ Air Contaminant Discharge Permit (ACDP).  This would allow the facility to add/replace/modify its equipment or processes as long as the emissions did not exceed the bubble limit.  We would like to replace the formal Notice of Intent to Construct (NC) procedures required for ACDPs with a simple notification letter. This would inform DEQ of changes being made and give the Department sufficient information to assure that the bubble would not be exceeded. 

14.	
Statement of Certification
The person at the facility responsible for implementing the environmental management system, i.e. the facility manager, should sign the following statement.  He/she should be able to verify the truth, accuracy and completeness of the contents of this application.  The name and title of the designated official and the date below may be handwritten or typed.  However, the signature must be handwritten and original.
I have reviewed this application and all supporting documentation in their entirety and to the best of my knowledge, information, and belief formed after reasonable inquiry, the statements and information contained herein are true, accurate, and complete.

Name of designated responsible official: Mary Williams
Title of responsible official: Facility Manager

Signature of responsible official					        Date:  February 15, 2000