4.3. ECCSR 06-20-2012Elk River – Energy City
Demonstration Project Information Form
Date:
Name of Project:
Company/Organization(s):
Address:
Contact Person:
Telephone Number:
E-mail:
Fax:
Sector (please check the appropriate): _ Agriculture _ Commercial _ Industrial
Institutional Residential
Brief description of the project and technology(ies) (attach any pertinent materials):
Energy Efficiency (please check all appropriate): _ Co- Generation _ Cooling
_Domestic Water Heating _ Energy Services _ Environmental Controls — Food
Preparation & Storage _ Fuel Cell _ Heating _ Heat Recovery _ Industrial &
Process Controls _ Insulation/Envelope _ Lighting _ Motors & Adjustable Speed
Drives _ Ventilation/Air Quality _ Water Conservation _ Windows
Renewable Energy (please check all appropriate): _ Biomass — Earth Sheltered
_ Geo- Source _ Hydro _ Methane —Photovoltaic _ Refuse - Derived Fuel
Solar Wind
Please check any appropriate:
—New project _ Existing project _ Retrofit
Date commenced: Date completed:
Project location:
Project cost (anticipated):
Expected or known results (ex. Measurements of air emissions, reduced water usage, energy
consumption reduction, etc.):
Anticipated benefits of the project (for whom)?
Target market or audience for product or service? What is the plan to market and
demonstrate the project?
Contact person to implement and promote the service or project (if not the person listed as
contact above):
As a representative for the company /organization(s) listed above, I am authorized to give
permission to Elk River Energy City to use project information, publicize the project as an
Energy City Demonstration Site, provide tours, or publicize vendor information in regard to
this project:
(Name and Title)
(Date)