Company / Facility Name: (required) Street Address: (required) City : State: Zip / Postal Code: Country: Number of Years at Current Location: Number of Years in Business: Contacts: Facility Manager: Telephone: Email: EH&S Manager: Telephone: Email: Audit Contact: Telephone: Email: 2.0 Facility Size, Scope, and Surroundings Warehouse Square Footage: Property Size (acres): Total Number of Employees Number of Shifts: Scope of Operations: AggregatorProcessorBroker Only Describe Area Surrounding Facility: Has facility received any notices of violations or fines within the last 5 years for environmental or H&S infractions? Are there any open or closed remediation activities on site property? 3.0 Permits, Licenses, and Insurance (attach appropriate evidentiary documentation) Business Licenses: Operating Permit: Environmental Permits Waste Permits: Air Emission Permits: Water Permits: Insurance Coverages: 4.0 Accepted Materials (check all that apply) Equipment for ReuseEquipment containing circuit boards (computers, servers, printers, copiers)CRT Monitors / TVs or CRT GlassLCD Monitors / TVs and/or Mercury Containing EquipmentBatteries and / or UPSCircuit Boards / Processors / MemoryPlastics 5.0 Processing Methods Repair and Refurbishment Manual Sorting Manual Disassembly Manual Disassembly Automated Sorting Shredding / Grinding Precious Metal Refining 6.0 Environmental, Health and Safety Management System Does the facility have a documented Environmental, Health and Safety Management System that encompasses its entire operations? YesNoN/A Evidence / Notes Has the facility been certified to ISO 9001, ISO 14001, OSHAS 18001, e-Stewards or R2? (Please include current certificates) YesNoN/A Evidence / Notes Does the company have a documented Environmental, Health and Safety policy? YesNoN/A Evidence / Notes How does the facility ensure compliance with applicable environmental, health and safety regulations? 7.0 Health and Safety Risks and Controls Does the facility's health and safety training including training for new hires, temporary workers, volunteers, and permanent employees? YesNoN/A Evidence / Notes How often is training conducted? Do employees conduct facility safety inspections? At what frequency? YesNoN/A Evidence / Notes Has the facility conducted hazard or risk assessments for all job positions? YesNoN/A Evidence / Notes Does the facility have a designated health and safety coordinator? YesNoN/A Evidence / Notes Has the facility conducted First Aid or First Responder Training? YesNoN/A Evidence / Notes How many days since the last Lost Time Injury (LTI)? What type of health and safety monitoring programs does the facility have in place? (air quality, noise levels) 8.0 EH&S Training Programs Has the facility conducted any of the following training programs? Hazard Communication YesNoNA Evidence / NotesEvidence / Notes Lockout-Tagout YesNoNA Evidence / NotesEvidence / Notes Bloodborne Pathogens YesNoNA Evidence / NotesEvidence / Notes Hearing Conservation YesNoNA Evidence / NotesEvidence / Notes Emergency Preparedness and Response YesNoNA Evidence / NotesEvidence / Notes Spill Response YesNoNA Evidence / NotesEvidence / Notes Hazardous / Universal Waste Management YesNoNA Evidence / NotesEvidence / Notes Focus Material Management Plan YesNoNA Evidence / NotesEvidence / Notes Respiratory Protection YesNoNA Evidence / NotesEvidence / Notes Industrial Trucks (Forklift) YesNoNA Evidence / NotesEvidence / Notes 9.0 Facility and Operational Controls Does the facility have a plan for evaluating environmental, health and safety risks of new material prior to receiving it? YesNoNA Evidence / Notes Describe the facility's security measures: Describe the facility's documentation and record keeping protocols: Does the facility maintain for at least three years commercial contracts, bills of lading or other commercially-accepted documentation for all transfers of equipment components and materials? YesNoNA Evidence / Notes 10.0 Waste Stream Management What types of waste does the facility generate? YesNoNA How does the facility handle Universal Waste items? YesNoNA How does the facility handle Hazardous Waste items? YesNoNA Is any material incinerated? YesNoNA