中美合同能源管理示范項(xiàng)目申報表

1、中美合同能源管理示范項(xiàng)目申報表申報單位名稱項(xiàng)目名稱項(xiàng)目領(lǐng)域工業(yè)【】，商業(yè)建筑【】，公共建筑【】，公共基礎(chǔ)設(shè)施【】，其他【】項(xiàng)目地址建筑面積（建筑項(xiàng)目填寫；平方米）項(xiàng)目實(shí)施時間預(yù)計(jì)完工時間項(xiàng)目類型分享型【】，保證型【】，能源費(fèi)用托管型【】，其他【】主要改造對象（至少三個系統(tǒng)）項(xiàng)目總投資主要融資方式項(xiàng)目單位改造前年綜合能源消費(fèi)量（請使用能耗單位）預(yù)計(jì)改造后年綜合能源消費(fèi)量（請使用能耗單位）項(xiàng)目參與方信息（中方項(xiàng)目至少一個美方參與機(jī)構(gòu)，美方項(xiàng)目至少一個中方參與機(jī)構(gòu)有更多參與機(jī)構(gòu)的，可增加表格填寫）節(jié)能服務(wù)公司名稱聯(lián)系人電話& 郵件用能單位名稱聯(lián)系人電話& 郵件技術(shù)供應(yīng)商名稱聯(lián)系人電話

2、& 郵件融資機(jī)構(gòu)名稱聯(lián)系人電話& 郵件項(xiàng)目基本情況描述：包括但不限于項(xiàng)目實(shí)施方介紹、項(xiàng)目總體狀況、項(xiàng)目改造措施、項(xiàng)目投資額、項(xiàng)目效果等項(xiàng)目創(chuàng)新點(diǎn)：對示范項(xiàng)目的創(chuàng)新部分進(jìn)行描述，包括但不限于技術(shù)創(chuàng)新、融資模式創(chuàng)新、合同模式創(chuàng)新、M&V創(chuàng)新、運(yùn)營管理創(chuàng)新等項(xiàng)目預(yù)期節(jié)能效果：描述預(yù)期年節(jié)能量、節(jié)能率以及評估與驗(yàn)證（M&V）方式申報單位授權(quán)代表信息姓名職務(wù)郵箱電話手機(jī)傳真通信地址及郵編申請單位承諾：我單位承諾上述信息屬實(shí)；我單位承諾：如果項(xiàng)目經(jīng)過工作組專家審核確定為備選示范項(xiàng)目，將每季度按要求向中國國家發(fā)改委、美國國務(wù)院和美國能源部指定單位聯(lián)系人（中國節(jié)能協(xié)會服務(wù)產(chǎn)業(yè)委

3、員會禹網(wǎng)霞 ；太平洋西北國家實(shí)驗(yàn)室太平洋西北國家實(shí)驗(yàn)室Meredydd Evans 和譚清 ）遞交項(xiàng)目進(jìn)展報告。 單位蓋章 年 月 日AppendixUS-China EPC Pilot Project Application FormName of Applying CompanyProject NameProject SectorIndustry【】，Commercial Building【】,Public Building【】， Public infrastructure【】Project LocationBuilding Area (Building Project; m2)Proje

4、ct Start DateAnticipated Completion DateProject modelShared savings【】, guaranteed savings【】, outsourcing【】, other【】Main Retrofit Systems (at least 3 systems)Investment AmountMain Financing MethodEnergy Consumption Before Retrofit(in original energy units)Anticipated Energy Consumption After Retrofit

5、 (in original energy units)Information of those involved with the project（Each project should have US-China elements, At least one ESCO and one Energy Consuming Company, additional institutions could also be added）ESCOContactPhone & EmailHost Company ContactPhone & EmailTechnology Provider C

6、ontactPhone & EmailFinancing InstitutionContactPhone & EmailBasic introduction of the project：Including but not limited to project implmentator's profile, project's overview (including facility type/purpose, average annual energy use, 

7、;retrofit measures planned (specify an integrated approach that will retrofit at least 3 systems), investment amount needed in the project, project expected results, etc.Innovation in the project：Describe innovation within the project, including but not limited to innov

8、ation in technology, financing method, contracting models(like guaranteed savings or other innovative model), measurements and verification(m=M&V), etcPredicted energy saving results of the project：Describe the yearly energy saving, energy saving percentage and their basis，M&V approach Autho

9、rized Representative InformationNamePositionEmailPhoneCellFaxPostal Address and CodeApplicants Promise：My company promises the information above are truthful;If the project is selected as a pilot project, my company promise to share and report project information quarterly to the government organizers NDR