Instructions. 7. Affidavits. 8. Self-audit Liability. 1. Entry information. 2. Participation and renewal. 3. Cost. 4. Self scoring and qualification

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1 Instructions Complete all areas of the form and tally your responses. If your plant/site qualifies, send the forms to the address below. You will receive a handsome plaque and materials to assist in publicizing your achievement within the community. For plants on permanent sites, all forms must be completed. For plants on temporary sites, all forms except the Permanent Site Community Relations form must be completed, and the appropriate forms in white must be completed as well. See the enclosed Checklist for clarification. 1. Entry information Mail forms to: In order for the plant/site to be recognized at NAPA s Annual Meeting, nominations must be postmarked no later than October Affidavits Affidavits may be signed by the following individuals: a local elected official (mayor, city or county council member); officer of a nearby homeowner's association; official of a civic group (Rotary, Kiwanis, Chamber of Commerce); Boy Scout or Girl Scout leader whose troop has toured the plant; or a teacher at a nearby school whose class has toured the plant. 8. Self-audit Liability The environmental and safety portions of this self-assessment are not comprehensive environmental and safety audits and should not be used for this purpose. However, your answers to the questions in these areas could be construed to be a "self-audit" for compliance with federal, state or local environmental/safety regulations. For these reasons, we would encourage a working understanding of the implications of "self-audits" before answering the questions. 2. Participation and renewal Participation is voluntary and is on an annual basis. Each plant/site may be submitted for the Commendation every year, at the company s option. 3. Cost The cost of participation is $400 per plant/site per year. Applications submitted during the early bird period (April 1 - June 30) pay a fee of $350. Please attach a check to your application. If you do not qualify, you do not owe the participation fee. 4. Self scoring and qualification To earn the Commendation, you must meet the threshold number for each of the six sections and you must earn at least 245 points overall. It is possible to score as many as 403 points on the selfassessment for plants on permanent sites or 413 for plants on temporary sites. If you do not qualify, do not send the form to NAPA. 5. Possible disqualification Some questions on the self-assessment deal with aspects of plant/site operations that are felt to be crucial. A No answer to any such question is treated as automatic disqualification. Do not forward the self-assessment to NAPA until the plant/site qualifies for the Commendation. 6. Additional forms Duplicate this form to nominate more than one plant/site, or contact the NAPA office (toll-free ) for additional copies. 1

2 Instructions 7. Specify whether this application is for: New application Full renewal application Streamlined renewal application 8. Answer this question first: Do you understand self-audit liability? Yes No If your answer is No, do not proceed with filling out this form until you can answer Yes. You may contact the Diamond Program Coordinator at NAPA for guidance. 9. Plant Information: Plant Owner: Plant Name or Designation: Plant (exact location): Plant Mailing (No P.O. Box): Distance to nearest neighbor of any type (residential, commercial, or industrial) from plant stack: Feet Site location (check all that apply) Urban Residential Industrial Quarry Rural Other (specify) Rated capacity Tons per hour Type of plant: Batch Counter-flow drum mixer Parallel-flow drum mixer Continuous mix Type of site: Permanent Temporary Does this plant/site routinely produce recycled mix? Yes No 2

3 Checklist Full Applications The following items must be completed and returned as part of the application. Plant permanently located on one site Instructions Section I, Appearance Section II, Operations (2 sides) Section III, Environmental Practices (2 sides) Section IV, Safety (2 sides) Section V, Permitting and Regulatory Compliance Section VI, Permanent Site Community Relations Self-Assessment Evaluation Permanent Site Affidavit Photos for full application (see listed requirements) Plaque Information Streamlined Renewal Applications The Diamond Achievement Commendation is designed for continuous improvement and excellence. Streamlined renewals are completed on an annual basis for two years following acceptance. The following streamlined renewal forms and documentation are required for the streamlined renewal process. Renewal Affidavit Photographs for streamlined renewal (see listed requirements) Mail forms, documentation, and check for full or streamlined renewal applications to: Plant temporarily located on more than one site Instructions Section I, Appearance Section II, Operations (2 sides) Section III, Environmental Practices (2 sides) Section IV, Safety (2 sides) Section V, Permitting and Regulatory Compliance Section VI, Permanent Site Community Relations Section VII, Temporary Site Community Relations Self-Assessment Evaluation Temporary Site Affidavit Either Form 1 or Form 2 Affidavit for Site Owned by the Asphalt Company (Form 1) OR Affidavit for Site not Owned by the Asphalt Company (Form 2) Locations on Which Plant was Temporarily Sited Photos for full application (see listed requirements) Plaque Information Photograph Requirements Full applications: Both digital photos and high-quality photo prints are acceptable. If you choose to submit digital photos, you must include a flash drive or CD with the electronic version of the photographs. Photos taken with a digital camera should be at least 960 x 1280 pixels. Scanned photos are not acceptable. Provide five to ten high-resolution photographs showing different views of the plant and site. One must be a long shot, showing the plant/site and its surroundings, and one must be of the plant entrance. Photographs must be taken during the current calendar year. Photographs may be used for marketing purposes. Streamlined renewal applications: Both digital photos and high-quality photo prints are acceptable. If you choose to submit digital photos, you must include a disk or CD with the electronic version of the photographs. Photos taken with a digital camera should be at least 960 x 1280 pixels. Scanned photos are not acceptable. Include one photo of the plant entrance and one photo of the truck load-out area during operation. Photographs must be taken during the current calendar year. 3

4 STREAMLINED RENEWAL Affidavit A streamlined renewal process is available for plant/sites that receive the Diamond Achievement Commendation. For the two years after the initial full application is approved, this streamlined form may be used. The full application packet including all forms and photographs are required in the third year and each successive third year. Name of company Name of plant/site (Outside third party optional for renewals only) Outside third party name and title /location of plant/site Name of organization We, the undersigned, do hereby affirm that we have reviewed the nomination form submitted in for the above-referenced plant/site, and that it is in substantially the same condition as it was at the time of nomination. Plant manager Division manager/executive Photographs: Both digital photos and high-quality photo prints are acceptable. If you choose to submit digital photos, you must include both prints and a disk with the electronic version of the photographs. Photos taken with a digital camera should be at least 960 x 1280 pixels. Scanned photos are not acceptable. Include one photo of the plant entrance and one photo of the truck load-out area during operation. Photographs must be taken during the current calendar year. Attach a check for $400 ($350 from April 1 to June 30) made out to. Number of date bars requested for plaques (One date bar per plaque) 14

5 NAPA s Diamond Achievement Commendation Plaque Information Please use this form to ensure that the wording on your Diamond Achievement Commendation for Excellence in Asphalt Plant/Site Operations is correct. Please type or print. Enclose this form with the nomination materials. Duplicate this form for more than one plant/site. You may include up to three lines. Company name, plant/site name, and plant/site city and state (location) are suggested. Please type or print within the box exactly as you wish the wording to appear on your plaque. (Horizontal lines will not appear on plaque.) If you would like to include your company logo on the plaque, you must enclose your logo in electronic format. Company logo accounts for one line in the above box. Note logo on the first line if you are including your logo. I am enclosing a logo for inclusion on the plaque. Successful first-time applicants (those submitting New Applications) for the Diamond Achievemnt Commendation will receive one plaque. Duplicate plaques may be ordered from NAPA at $250 each. Applicants for Streamlined or Full Renewals are also invited to order plaques at $250 each. Yes, I would like to order additional plaques. No, I do not wish to order additional plaques. Authorized Name/Title (Please print) Fax Shipping (es) for Plaque(s) (no P.O. Boxes) Attach extra sheet for additional plaque orders. Company Name Name/Title City State Zip 16