United States
Environmental Protection
Agency
OMB Control No. 2060-0578
Approval Expires 04/30/2009
Partner's Letter of Intent
for State, Local, Tribal Agencies
§ CHP
AEPA COMBINED HEAT AND
POWER PARTNERSHIP
F
Please fax the completed Letter of Intent (2 pages) to 617/482-1320 (contractor in support of EPA)
With this
joins EPA
benefits c
Sincerely,
Name:
Title:
letter (State/Local/Tribal Agency)
's Combined Heat and Power (CHP) Partnership and commits to work with EPA to promote the
>f CHP and support development of new CHP projects within our state/locale.
Authorized State/Local/Tribal Agency Representative Signature
Date:
The State/Local Partner Agrees to:
1. Designate a liaison for EPA's CHP Partnership.
2. Host a workshop to promote the benefits of CHP and support development of new CHP projects within the
state/locale.
3. Provide input to EPA-developed CHP Partnership tools and services, including state/locale-specific data and
analysis.
4. Employ CHP Partnership tools and services, as appropriate, to recognize and promote CHP development within
the state/locale.
EPA Will:
1. Support the State/Local Partner with tools and services including state/locale-specific data and analysis.
2. Support the State/Local workshop through logistics and planning.
3. Designate a Program Manager as Partner liaison.
General Terms:
1. This agreement can be terminated by either party, at any time, without prior notification, penalties or further
obligation.
2. The State/Local Partner agrees that the activities it undertakes associated with this voluntary agreement are not
intended to provide services to the federal government and that the Partner will not seek compensation from a
federal agency.
3. The State/Local Partner agrees that it will not claim or imply that its participation in the Partnership constitute EPA
approval or endorsement of anything other than its commitment to the Partnership.
Please complete the information on page 2.
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State Partner's Liaison:
Name:
Title:
State/Local Agency:
Address:
City: State: Zip:
Telephone: Fax:
E-mail:
Additional Partner Information:
Your agency's Web site address:
Does your agency have a CHP-related Web page? If so, please list here:
May we provide a link to your CHP-related Web page? D Yes D No
Please provide a brief profile of your agency's involvement in CHP. (If the space below is not adequate, please mail or
fax this information to us on separate pages, along with your signed Letter of Intent.):
The government estimates the average time needed to fill out this form is 4.9 hours and welcomes suggestions for reducing this level of effort. Send comments
(referencing OMB control number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
PLEASE FAX THE COMPLETED LETTER OF INTENT TO 617/482-1320 (contractor in support of EPA)
United States Office of Air and Radiation EPA-430-F-05-035
Environmental Protection (6202J) www.epa.gov/chp
Agency October 2005
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