Draft Example Mitigation Plan Acme, Inc. Firewood, ME Wood Burning Appliance Replacement and Retrofit Project Mitigation Plan October, 2011 ------- Pursuant to Section VI and Appendix B) of the Consent Decree ("Consent Decree") between the United States of America and Acme Inc. (collectively, "Defendants"), this work plan describes the method by which Defendants will implement a Supplemental Environmental Project ("SEP") or Mitigation Plan consisting of sponsorship of a wood burning appliance replacement and retrofit project (the "Project") in specified geographical areas in New England. As authorized by the Consent Decree, Defendants will utilize a third-party non-profit agency - the WE CAN HELP Association (WCHA) of New England - to implement the Project. The Project is intended to achieve reductions in fine particle pollution and/or hazardous air pollutants in both indoor and outdoor air by replacing or retrofitting older non-EPA certified/qualified wood stoves, hydronic heaters (a.k.a. outdoor wood boilers) and fireplaces with new, cleaner burning devices (for example Energy Star gas furnaces, EPA certified wood stoves, gas stoves, or wood pellet stoves). I. IDENTIFICATION OF THIRD-PARTY NON-PROFIT SELECTED TO IMPLEMENT THE PROJECT Defendants have selected the WE CAN HELP Association of New England ("WCHA"), a not- for-profit voluntary health organization whose mission is "to save lives by preventing air pollution" to implement the Project. The WCHA works to achieve its mission through research, education and advocacy, and has an impressive record of successfully promoting initiatives to improve air quality throughout New England. II. SCHEDULE AND BUDGETARY INCREMENTS FOR FUNDING OF WCHA Pursuant to the Consent Decree, Defendants are required to spend no less than $xxx,000 in Project Dollars (as such term is defined in the Consent Decree) to perform the Project, and must limit the use of Project Dollars for administrative costs to no greater than 10% of the Project Dollars. The WCHA has agreed to implement the Project for the sum of $xx,000 ("Administrative Fee"), meaning that $xxx,000 will be used for the retrofit or replacement of non-EPA certified wood stoves, fireplaces, old technology outdoor wood-fired hydronic heaters) with, cleaner burning, more energy- efficient heating appliances (e.g., Energy Star qualified geothermal heat pumps and natural gas furnaces, wood pellet stoves, gas stoves, EPA- 2 ------- certified energy efficient wood-stoves or EPA qualified fireplace and hydronic heater retrofit devices). Defendants will disburse the Administrative Fee to the WCHA according to the following schedule: • 50% of the Administrative Fee within 30 days of the final EPA approval of this Project work plan; • an additional 25% of the Administrative Fee on the six-month anniversary of the date of first payment, as set forth above; and • the remaining 25% of the Administrative Fee upon completion of the Project, i.e., when all Project Dollars are spent. Funding for Rebates WCHA will receive the funding from Defendants to pay for the voucher rebates involved in the Project. The WCHA will issue checks or electronic funds transfer to the qualified dealers once it receives the documentation described elsewhere herein. WCHA will set up a restricted account and will bill Defendants monthly. Note: this is one option there are other ways to manage the transfer of funds. III. SCHEDULE FOR SUBMISSION OF REPORTS BY DEFENDANTS Pursuant to Paragraph 31 of the Consent Decree, within thirty (30) days of the end of each calendar quarter after lodging of the Consent Decree, Defendants are required to submit quarterly reports for the preceding calendar quarter. Defendants shall include within each quarterly report a summary of the following activities and information: 1. Activities Conducted During Reporting Period • Description of educational outreach activities conducted by the WCHA o media spots o web outreach o brochure development/distribution • Number of applications for new, cleaner burning devices received • Number of applications for new, cleaner burning devices accepted o geographic location of each accepted application • Number and type of cleaner burning appliances • Number of older appliances retrofitted • Number of older appliances removed 3 ------- • Method/location of disposal or recycling of older appliances replaced • Total project dollars spent during the quarter and cumulatively o type/amount of reimbursement For each older appliance removed, documentation concerning the disposal of such device shall be appended to each quarterly report, or, if not yet available, shall be included with the next quarterly report. 2. Anticipated Activities for the Next Reporting Period 3. Project Percentage Completion (Approximate) IV. ACTIONS TO ENSURE THE WCHA WILL IMPLEMENT THE PROJECT IN ACCORDANCE WITH CONSENT DECREE Defendants and the WCHA have extensively discussed the Project requirements imposed by the Consent Decree, including the requirements in Appendix B thereto. As a result of these discussions, Defendants and the WCHA have agreed that this work plan will serve as the agreement between the two parties with respect to the Project. V. ELEMENTS OF PROJECT TO BE IMPLEMENTED BY WCHA The objective of the Project is to achieve maximum air quality benefits through the use of $XXX,000 in project dollars for the retrofit or replacement of non-EPA certified stoves, old technology hydronic heaters and open fireplaces with new, cleaner burning heating appliances and retrofit devices. The geographical area of Project implementation is limited to Money, Hopscotch and Rockfish counties in NE (the "Geographic Area"). 1. General Approach to Project Implementation The WCHA plans to implement the Project using a staff coordinator who will work with WCHA State Director of Health Promotion and Public Policy for New England to oversee the Project in the Geographic Area. The WCHA's Project outreach will rely heavily on earned media (news articles, letters to the editor, op-ed submissions, radio/television interviews, etc.). The WCHA will use its Leadership Board members in NE as spokespersons for the Project and to attract key partners, volunteers and customers. Potential Partners: The WCHA will promote the Project in the (Name geographic area) by focusing on participating heating appliance retailers, chimney sweeps, pellet 4 ------- suppliers, major businesses, health and medical care organizations, fire departments, media representatives, social service groups and others who can reach large numbers of people and may share its goal of improved air quality and public health. (See section 2b for more detail). Co-marketing the Project with these key organizations will be a key strategy for public education and participant recruitment. As an example, the WCHA is an active member of the Asthma Health Improvement-Asthma Educator Network in Snow Fall Valley Asthma Coalition. Due to the potential for significant reduction in indoor and outdoor pollution from the Project, the asthma coalition is likely to be very helpful in promoting the Project among the asthma educators in New England. Website: The WCHA's website will be updated to feature the Project and serve as the key point of entry for information for participants as well as participating retailers. The WCHA will also ask its partners to use their websites and email lists to promote the Project and to link to the WCHA site. Toll-free Line: The WCHA's toll-free telephone Helpline will enable interested participants and potential partners and sponsors to get information and become involved. Posters and Brochures: Posters and brochures used in the previous projects and provided by EPA will be modified for this Project and distributed through the retailers and in other community locations. These posters and brochures will be forwarded to the EPA for review and comment prior to distribution. Media Outreach: Given the funding level available for administration and advertising for the Project, the WCHA will implement a project marketing plan that will rely largely on "earned" media (e.g. news stories, letters to the editor, op-ed submissions, talk radio, company newsletters and email blasts, etc) as a way of educating the public about the advantages of cleaner burning stoves, proper operation and publicizing the Project. There are a number of media outlets servicing the Geographic Area and the WCHA's Project Coordinator will reach out to those listed in Appendix A. Retailer Information: The WCHA will work with the Hearth Patio and Barbeque Association whose New England office can help recruit retailers. The WCHA will supply its participating retailers with EPA "Burn Wise" materials (e.g., Wet Wood is a Waster brochure) to be distributed with each new wood burning appliance to stress the need to burn wood properly. Whenever possible, the WCHA will 5 ------- also take advantage of opportunities from any of its participating retailers to obtain sponsored advertising. 2. Specific Program Components a. Partnership Development Heating Appliance Retailers: The most essential partnership is with retailers that sell and install wood- burning appliances, retrofit devices and other heating appliances in the Geographic Area. The WCHA will identify heating appliance retailers who are interested in participating. The WCHA will formally enlist them through a written agreement that will identify the retailer as a participant. The agreement will stipulate: a) that they will accept the Project vouchers as an instant rebate; b) follow best practices in appliance installation procedures, and c) attest that they will remove and properly recycle or dispose of older stoves. Only qualified retailers with signed agreements will be used by the Project (see Appendix B). Retrofit or replacement of new, cleaner burning appliances will be done by professionals in conformity with all applicable state and local codes and/or be installed by certified by professionals, (e.g., National Fireplace Institute, the Chimney Safety Institute of America, or an equivalent organization). This is noted on the voucher application form (see Appendix C). Business Community: Another key partner will be the business community in the Geographic Area. The WCHA will contact the local Chambers and other traditional community service organizations, such as the local Rotary Clubs, Lions Clubs, etc. These organizations are a good point of entry into the local business community and are often looking for educational programs for their membership. The WCHA will seek the assistance of these groups and their members to promote the Project among their employees, customers, family and friends. Some businesses may want to supplement the "rebate" being provided as a way of helping their employees purchase retrofit or replace non-EPA certified 6 ------- stoves with new, cleaner burning technologies. Pellet manufacturers will be approached directly and/or through the stove retailers and asked to consider giving away a supply of pellets or providing some other incentive to Project participants who purchase pellet stoves. This same approach will be taken with gas suppliers. Health Care Providers: The WCHA has relationships with many health care providers and institutions in the Geographic Area. The WCHA intends to work closely with its health care system colleagues who will be asked to have their institutions or companies promote the Project among staff and the communities they serve by stressing the health improvement aspect of the Project. The improvements in indoor air quality from the Project are potentially substantial (over 70% reductions in particulates). This information will be especially useful to anyone with a chronic illness who is currently burning wood using an older stove and to those health care providers, like home oxygen companies or home health aides, who provide services to those with chronic illnesses. b. Education and Outreach As stated above, the WCHA will use its relationships in the Geographic Area as key distribution channels for education and for promoting Project participation. While this is one venue for education and outreach, the WCHA is also very skilled in educating the public on a variety of health issues through "earned media." WCHA will use its existing clipping service and other means of tracking media impressions. Project staff will make personal contact with the key media in the Geographic Area. Kick-off Event: The WCHA believes the media will find the Project to be newsworthy and can be persuaded to report on it periodically. The WCHA plans to conduct a Project kick-off press conference, to not only publicize the Project, but to identify media contacts who seem especially interested in the Project. The WCHA will invite an EPA spokesperson to this event to highlight the Project's national, regional and local significance. Participating retailers will also be invited, as will a representative of Acme Inc. The WCHA will consider doing a "soft launch" of the Project where a limited number of vouchers would be issued and redeemed prior to the Project kick-off to allow it to have some "real life" stories shared at the press event. The Project has many interesting angles for the media to highlight from its air quality impacts to the human interest story appeal of replacing an older stove for a low-income family, possibly even one with a child suffering from asthma. 7 ------- Communicating the Benefits: The WCHA will provide educational outreach about: the Project and the benefits of retrofitting or replacing non-EPA certified stoves with new, cleaner burning appliances; proper operation and installation of the cleaner burning appliances and a description of the financial incentives of the Project. The WCHA will use the tools outlined in the Section V 1. above and work with the partners previously identified to raise awareness about the program and its benefits. The WCHA will use the existing educational resources on the EPA website at http://www.epa.gov/burnwise on how to burn wood properly and adapt program promotional material from other change-out projects. In addition, there are excellent consultative resources available at the EPA, the Hearth, Patio and Barbecue Association and the Chimney Safety Institute of America that will be helpful. The WCHA will also prepare a simple presentation about the Project that is localized to the Geographic Area and can be used by the Project coordinator, the ALA in New England Leadership Board members, volunteers, and others for public talks. c. Project Operation The WCHA will assume sole responsibility for the operation and management of the Project (see draft timeline Appendix D). This will include, but not be limited to, the following: • Recruitment, hiring and supervision of Project staff; • Preparation, distribution and processing of applications for wood- stove replacement vouchers from homeowners using a form from our Massachusetts project (see Appendix C ); • Administration of the financial incentive program: o The WCHA will issue vouchers to homeowners based upon receipt of a completed application form that includes a certification section in which the applicant agrees to a number of requirements for participation (see Appendix E). o This voucher will be redeemed only at participating retailers with whom the WCHA has signed agreements and who are using its Voucher Tracking Form (see Appendix F) to get reimbursed. Among those requirements are the following: ¦ attesting that an operating older stove will be retrofitted or replaced with a new, cleaner burning device; 8 ------- ¦ that the older device will be removed and properly recycled by the retailer; ¦ that the replacement device will be purchased prior to the voucher expiration date (usually 3-4 weeks) and, ¦ a picture before and after installation will be submitted to WCHA. • Voucher Tracking: o Participating retailers will submit the Voucher Tracking Form to redeem each voucher. o The tracking form will be sent to the WCHA, along with the before and after photos, the original voucher, an invoice for the purchase, validation that the older stove was recycled, as required. o The Voucher Tracking Form and accompanying documentation will be scanned and emailed to the WCHA's contact at Defendant's office for review and approval. o Upon approval, the WCHA project coordinator will submit the paperwork to the WCHA business office for payment. • Proper Operation and Education: o Retailer must ensure the recipient of the new appliance/retrofit purchased through this incentive program reviews/demonstrates proper operation of the new appliance. o Retailer must provide educational materials (e.g., Burn Wise fact sheet, brochures) and explain the benefits (e.g., lower emissions, better efficiency) of proper wood burning techniques, including the use of dry seasoned wood for wood burning appliances. • Wood Burning Replacement Options o Non-EPA certified wood burning appliances stoves must be replaced by a new cleaner burning appliance/retrofit devices (e.g., gas stove or furnace, pellet stove, EPA certified wood stove, EPA qualified hydronic heater) 9 ------- o The plan is to allocate the resources available to retrofit or replace stoves, as follows (this is subject to modification as the Project moves forward): Vouchers for wood burning appliance replacement options include the following: Wood-stove, Fireplace/Boiler Replacement Options Incentive 1 Energy Star qualified geothermal heat pumps, EPA Phase 2 hydronic heaters (Biomass wood pellets; continuous feed fuel only) Up to $6,000 2 Hydronic heater retrofit kit (heaters must be less than 7 years old) Up to $2,000 3 Energy Star natural gas boilers and gas furnaces Up to $2,500 4 EPA certified wood-stoves (4.5 gram/hour or less) Up to $1,000 5 Gas or wood pellet energy efficient hearth appliances Up to $1,750 6 EPA Qualified retrofit device or gas appliance for open fireplace Up to $500 * Program may want to include EPA Phase 2 qualified hydronic heaters. • Reporting o WCHA shall ensure that the report includes materials and/ or verification of compliance with the Consent Decree and spells out the public benefits. o With respect to Acme Inc.'s quarterly reports due under the Consent Decree, WCHA shall complete and submit such reports not later than the 10th calendar day of the month in which the report is due. Compilation and reporting on a participant satisfaction survey (see Appendix F) Appendices A. Geographic Area Media Outlets B. Retailer Application Form C. Voucher Application Form D. Project Timeline E. Voucher Tracking Form F. Participant Satisfaction Survey 10 ------- APPENDIX A Project's Geographic Area Media Outlets Location: Grand County Name of Print Contact Information Daily Times doe.iohn@dailytimes.com Weekly Herald smith.iohn@weeklyherald.com TV List of TV networks Radio List of Radio stations Location: Lincoln County Name of Print Daily Times Weekly Herald TV List of TV networks Radio stations Contact Information doe.iohn@dailytimes.com smith.iohn@weeklyherald.com Contact Information Contact Information List of Radio ------- Appendix B - Retailer Application Form Pa rties: This Retailer Agreement ("Agreement") is for services between the WE CAN HELP Association of New England (""WCHA"). 45 Ash St. Hartford CT 06108, and , of (hereinafter called ""Subrccipient"). effective as of the last date indicated below. Subject Matter: The subject matter of this Agreement is a wood stove change-out program. Detailed services to be provided by the Subrecipient pursuant to this Agreement are described in Attachment A, which is incorporated by reference herein. Maximum Amount: In consideration of the services to be performed, the WCHA agrees to pay Subrecipient, in accordance with the payment provisions specified in Attachment A, a sum not to exceed $1,000 per new EPA certified wood stove replacement voucher; $1,750 for a new pellet or gas stove voucher; $6,000 for a new cleaner burning gas furnace, geothermal, EPA Phase II hydronic heater voucher and up to $2,000 for a retrofit voucher Agreement Term: The period of Subrccipient's performance shall begin upon date of execution, signified by the date of signature by the WCHA, and end on or before June 30, 2013 or, if earlier, the date on which all Project Dollars are spent. Amendment: No changes, modifications, or amendments in the terms and conditions of this Agreement shall be effective unless reduced to writing, numbered, and signed by the duly authorized representative of WCHA and Subrecipient. Any request for an amendment to this Agreement must be made in writing at least 30 days prior to the end date of this Agreement or the request may be denied. Cancellation: This Agreement may be cancelled by either party by giving written notice to the other at least_30days in advance; provided , however, that WCHA may terminate this Agreement immediately for reasons stated in Attachment A, incorporated by SubreciDient Proaram Contact: Name: Phone: E-mail: SubreciDient Fiscal Contact: Name: Phone: E-mail: WCHA's Proaram Contact: Name: Jane Doe Phone: (207)624-0000 E-mail: WCHA's Fiscal Contact: Name: John Doe Phone:(860)838-0000 E-mail: Attachments: This agreement also consists of the following attachment(s) that are incorporated herein:® Attachment A - Standard WCHA Provisions • Attachment B - Voucher Tracking Form WE CAN HELP Association of New England: Date: John Smith, President and CEO ------- APPENDIX C VOUCHER APPLICATION FORM 1. Entire How the Rebate Program Works 1. WCHA is offering rebate vouchers valued between $1,000 and $4,000 to homeowners in Hopscotch, Rockfish and Money Counties in New England for retrofit or replacement of non-EPA certified wood stoves or hydronic heaters (a.k.a. outdoor wood boilers) and with new, cleaner burning devices. To qualify for a rebate voucher, the homeowner must first complete the application below. Applications for rebate vouchers will be accepted until March 31, 2013 or Project Dollars are depleted. Please include a photo of the currently installed older stove. Completed applications must be signed by the homeowner and mailed to the program coordinator at the address below. 2. The Southern New England Wood Burning Change-out Project Coordinator will review the applications to determine if the preliminary qualification requirements have been met. Qualified applicants will receive a rebate voucher worth $1,000 for a new EPA certified wood stove, $1,500 towards a new pellet or gas stove, $6,000 towards a new EPA Phase II hydronic heater (see modification on page 9), or up to $2,000 for a retrofit device. Rebate vouchers will be valid for four (4) weeks. Special low income vouchers of up to $3,000 are available to those who can show proof of participation in the Low Income Heating Assistance Program, Women Infants and Children Supplemental Food Program, or state Medicaid and the time of application. 3. The homeowner may use the rebate voucher to retrofit or replace a non-EPA certified stove with a new, cleaner burning device from a participating retailer only, provided the voucher has not expired. Vouchers will be applied as an instant rebate off the total price of the stove. No retroactive rebates are allowed. Voucher expiration date may be extended at the discretion of WCHA. 4. New, cleaner burning devices must be professionally installed in accordance with local fire and building codes. The EPA recommends that installers be National Fireplace Institute or Chimney Safety Institute of America certified (or an equivalent organization). The installation must be coordinated and certified by the participating retailer. No do-it- yourself installations are allowed under this program. ------- 5. Older stoves that were replaced through the program must be permanently removed from service and surrendered to the participating retailer, who will render them inoperable and coordinate their disposal and recycling. 6. The participating retailer will take a photo of the older stove prior to removing it and will also take a photo of the replacement stove after it is installed. VOUCHER APPLICATION FORM All sections of this application must be completed. A copy should be retained by the homeowner for his or her records. The rebate program is not responsible for materials lost by mail. Please review the program terms prior to signing below and submit your completed application with attachments by mail, or hand delivery to: Jane DoeChange-out Project Coordinator WE CAN HELP Association 122 State St Firewood, IN, 47035 Applicant Information: Name: Physical Home Address (where older stove is located): Mailing Address (if different): Phone Number: Email (if available): Current Wood Burning Stove: Make/Model: Est. Year Stove Manufactured: ~ I have included a picture of my older stove ~ I am applying for the following voucher: ~ Wood stove $1,000 ~ Pellet or Gas $1,750 ~ Gas heater, $2,500 ~ Geo thermal, Phase II OWB $6,000 ~ Retrofit - up to $2000 ------- Additional Information: 1. How did you hear about the Change-out Program?. 2. Why are you applying? (Please check all that apply.) ~ Not satisfied with current device; ~ To reduce pollution; ~ To save money ~ Other: 3. Was the rebate a significant factor in replacing your stove? ~ Yes ~ No 4. In a typical heating season, how many cords of wood do you typically burn? 5. Is your wood stove used as a primary source of heat? ~ Yes ~ No 6. Do you know how old your stove is? If yes, how old: years CERTIFICATION: I certify the following: a. I understand that only currently installed and operating non-EPA certified wood stoves are eligible to be replaced under this program. b. I understand that participants are limited to receiving one rebate voucher per address. c. I understand that applications are processed in the order they are received. Rebates will be distributed on a first-come, first-served basis. Funding is limited; rebates are not guaranteed. The voucher will only be valid for four weeks from the date of its issuance. No retroactive rebates are available. Voucher expiration date may be extended by at the discretion of the WCHA. d. I understand that applications may only be accepted for residences in Rock, Mack and Hillsborough Counties. e. I understand that if I qualify, I will receive a voucher and a current list of participating retailers who will honor the voucher if it is submitted by the expiration date written on the voucher. f. I will be retrofitting or replacing an operable non-EPA certified wood stove that is currently in use in my residence. The participating retailer who installs the new device is responsible for properly dismantling and disposing of the old device. g. If I choose to retrofit or replace a device with funds from this program, I will make a commitment to purchase a device from a participating retailer within the four (4) week period and authorize the retailer to forward to the WCHA a notification of the purchase agreement, with verification that my existing wood stove is not EPA-certified. ------- h. I understand that devices purchased with funds from this program will be professionally installed and that there will be additional costs for installation and a permit from my community if required for installation. Installations must comply with all local fire and building codes. The installers must be certified (e.g., National Fireplace Institute, the Chimney Safety Institute of America, or an equivalent organization). The installation must be coordinated and certified by the participating retailer. i. I understand that I am responsible to pay the retailer for the purchase price and professional installation costs of my new device, less the rebate amount. j. I understand that I will forfeit my voucher if I provide the WCHA with false information or fail to obtain any required permit or if the required information is not submitted to the WCHA prior to the expiration date listed on the voucher. k. The WCHA does not warranty any devices purchased under this rebate program, including, but not limited to, the quality, functionality or satisfaction of the device. I. I understand that proper wood burning practices (e.g., burning only dry seasoned wood) and proper stove installation and operation (e.g., maintaining a hot fire) are critical to the effectiveness of my new device. Applicant Signature: Date: 2 ------- APPENDIX D Project Timeline DRAFT* October 2011- November 2011 • Hire part time staff and recruit specific New England volunteers from the board • Recruit participating retailers • Establish voucher rebate application process; tracking protocols and retailer rebate procedures and educate retailers • Create website as part of WCHA site • Create and distribute posters/brochures • Plan for official "kick-off" media event • Peak promotion and installation period • Earned media priority • Presentations throughout the Geographic Area December 2011- March 2012 • Continue to build awareness about the Project • Business group presentations • Focus on "Burnwise" education • Human interest stories on satisfied participants • Prepare for Spring "kick-off" ------- April 2012- November 2012 • New season "kick-off" • Emphasis on earned media and co-sponsored ads • Heavy Project promotion period • Assess Project success to date and modify, as needed December 2012- August 2013 • Implement any necessary Project changes • Continue project operations • Compile final report and financials • Close out Project ------- APPENDIX E VOUCHER TRACKING FORM This form is to be completed by participating retailers * and sent to: Michelle Edwards, NH Wood Burning Appliance Change-out Program, The WE CAN HELP Association, 122 State Street, Augusta, Maine 04330. See "Checklist" on page 2. Date: Voucher #: Consumer's Name: Phone: Address: City: County: State: Zip: New Cleaner Burning Device Manufacturer: Model: New Appliance Type: Wood ~ Pellet ~ Gas ~ Other: ~ Retrofit Description (if applicable): Retailer Name: Phone Retailer Address: City: State: Zip: Installation Name of Certified Installer**: Old Non-EPA Certified Wood Stove Manufacturer: Model: I certify that the old stove was not EPA-certified (NOTE You will ONLY be reimbursed for replacing stoves that are NOT EPA certified: Yes ~ I certify that the old stove was in-use prior to replacement: Yes ~ I certify that the installed device was new: Yes ~ Page 2 of 2 2 ------- Recycling (for Replacement Projects): I certify that the old wood stove has been removed from the residence: Yes ~ I certify that the old wood stove's doors have been removed and hinges destroyed prior to the stove's release to a recycling facility: Yes ~ I certify that the old wood stove has been released to a recycling facility, with its doors removed, and that the stove is to be destroyed: Yes ~ Name of Recycling Facility: Signature (recycling facility): Date: I certify that the information contained on this tracking form is accurate and the form is completely filled-out. I also agree that I must meet the program requirements and be a participating retailer in order to receive reimbursement from the WE CAN HELP Association in New England. This form must be submitted with ALL sections completed especially the recycling section, along with the rebate voucher, a copy of the invoice, photograph of stove prior to removing it AND of newly installed stove in order to receive reimbursement. Name of Participating Retailer: Signature: * Participating retailers must be registered with the WE CAN HELP Association in New England. ** EPA recommends that installers be professionally certified (e.g., Chimney Safety Institute of America or National Fireplace Institute) To assure quick processing, please make sure you send all items listed. Checklist: ~ Rebate Voucher enclosed ~ Pre and post installation photos ~ Copy of invoice ~ Signature of recycler (on form) ~ Your signature (on form) Mail all to: Jane Doe NH Wood stove Change-out Program WE CAN HELP Association 122 Main Street Snow Valley,, Maine 04330 3 ------- APPENDIX F Change-out Customer Satisfaction Survey As a participant in the recent Wood stove Change-out Program with WCHA, please take a few moments to reflect on your experience with the program. This survey is designed to gather input regarding your satisfaction with the program and the process. 1. On a scale of 1-10 (with 10 being "most satisfied"), how satisfied were you with the Wood stove Change-out Program as a whole? ~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10 2. How did you hear about the program? (check all that apply) ~ A poster at a local business ~ A radio announcement ~ A newspaper ad ~ From participating dealer ~ Word of mouth ~ Other (please specify): 3. Do you think your rebate was too much, too little, or just right? ~ Too much ~ Too little ~ Just right 4. What was your experience with the application process? ~ It was easy ~ It was confusing and/or difficult ~ It was difficult but I was able to easily get answers to any questions I had. ~ 01 h e r (please specify): 5. If you have any suggestion(s) on how the application process could be improved, please indicate below: 6. Where did you purchase your new appliance? ~ Name of local store #1 ~ Name of local store #2 ~ Name of local Store #3 ------- 7. On a scale of 1 - 10 (with 10 being "most satisfied"), how satisfied were you with the participating dealer? ~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10 Comments: 8. On a scale of 1 - 10 (with 10 being "most satisfied"), how satisfied were you with the INSTALLATION of your new heating appliacne? ~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10 Comments: 9. On a scale of 1 - 10 (with 10 being "most satisfied"), how satisfied were you with your new heating appliance? ~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10 Comments: 10. After installing your new heating appliance, during this past heating season did you notice any difference in heat output? ~ Yes, I noticed greater heat output ~ Yes, but the heat output seemed to be less ~ No, I did not notice a difference ~ Not applicable, due to timing of installation ~ O t h e r (please specify): ------- 11. After installing your new heating appliance, did you notice any difference in the amount of fuel used? ~ Yes, I used less fuel ~ Yes, I used more fuel ~ No, I didn't notice any difference ~ Fueltype changed, so I was not able to compare ~ Not applicable because of timing of installation ~ 01 h e r (please specify): 12. If still burning with wood, after the change-out, did you notice more or less smoke coming from the chimney? ~ More ~ Less ~ About the same ~ Not sure I didn't notice 13. After the change-out, did you notice more or less smoke INSIDE your home? ~ More ~ Less ~ About the same ~ Not sure I didn't notice 14. Aside from the voucher, what was your main motivation for participating in the program? If you choose more than one answer, indicate your 1st, 2nd, 3rd, etc. choice. Improved energy efficiency Improved indoor air quality Improved outdoor air quality Improved safety Less time and energy handling wood Other 15. What suggestions would you make to improve the program? Thank you for taking the time to complete this survey. Your answers will help improve future wood stove change-out programs, should funding become available. ------- |