Please complete the form below and return to VH TechWorks :

Please complete the form below and return to VH TechWorks :

1.0 Company and Facility Contact Information


2.0 Facility Size, Scope, and Surroundings

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 Reuse
Equipment containing circuit boards (computers, servers,printers, copiers)
CRT Monitors / TVs or CRT Glass
LCD Monitors / TVs and/or Mercury Containing Equipment
Batteries and / or UPS
Circuit Boards / Processors / Memory

5.0 Processing Methods

Method /Materials Processed
Method /Materials Processed
Method /Materials Processed
Method /Materials Processed
Method /Materials Processed
Method /Materials Processed

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?
Yes No N/A
Has the facility been certified to ISO 9001, ISO 14001, OSHAS 18001, e-Stewards or R2? (Please include current certificates)
Yes No N/A
Does the company have a documented Environmental, Health and Safety policy?
Yes No N/A
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?
Yes No N/A

How often is training conducted?

Do employees conduct facility safety inspections? At what frequency?
Yes No N/A
Has the facility conducted hazard or risk assessments for all job positions?
Yes No N/A
Does the facility have a designated health and safety coordinator?
Yes No N/A
Has the facility conducted First Aid or First Responder Training?
Yes No N/A

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
Yes No N/A
Yes No N/A
Bloodborne Pathogens
Yes No N/A
Hearing Conservation
Yes No N/A
Emergency Preparedness and Response
Yes No N/A
Spill Response
Yes No N/A
Hazardous / Universal Waste Management
Yes No N/A
Focus Material Management Plan
Yes No N/A
Respiratory Protection
Yes No N/A
Industrial Trucks (Forklift)
Yes No N/A

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?

Yes No N/A
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-accepteddocumentation for all transfers of equipment components and materials?

Yes No N/A

10.0 Waste Stream Management

What types of waste does the facility generate?

How does the facility handle Universal Waste items?

How does the facility handle Hazardous Waste items?

Is any material incinerated?
Yes No N/A

11.0 Repair and Refurbishment Operations

Does the facility refurbish, repair, and resale tested equipment?

Yes No N/A
How are functions of equipment tested and results captured?

Does the facility sell and label equipment into the 3 classifications to meet R2:2013 Clause 6C?

       - Tested and Full Functions / R2 Ready for Reuse

       - Tested for Key Functions / R2 Ready for Resale

       - Evaluated and Non-Functioning / R2 Ready for Repair

Yes No N/A

Does the facility perform data destruction services?

Yes No N/A

Are data destruction procedures documented?

Yes No N/A

Are data destruction procedures compliant with NIST800-88?

Yes No N/A

Do employees involved in the data destruction process receive training?

Yes No N/A

Is the data destruction process validated by an independent party on a periodic basis?

Yes No N/A

Are appropriate methods maintained to verify data destruction processing?

Yes No N/A

Is equipment packaged in a sufficient manner to prevent damage?

Yes No N/A

Does the facility offer a warranty or take back program for equipment that does not meet expectations or functionality results?

Yes No N/A

12.0 Downstream Vendor Management

Does the facility evaluate downstream vendors that receive recovered material from its operations?

Yes No N/A
How is the evaluation conducted?
At what intervals are downstream vendors evaluated?

Please complete the downstream vendor management table for your facility’s operations on the following page.

12.1 Downstream Vendor Management Table

Tier 1

Tier 2

Tier 3

12.2 Downstream Vendor Agreement

VH Techworks, LLC requests that all downstream vendors receiving material that contains Focus Materials (Mercury, Circuit Boards,CRTs and CRT Glass, Polychlorinated Biphenyls (PCBs), and Batteries) agree tothe following requirements:

1.    Adhere to the enclosed Focus Material Management Planfor material received from VH Techworks, LLC.

2.    Maintain a documented environmental, health, and safetymanagement system.

3.    Maintain a list of its environmental permits and copiesof each.

4.   The downstream vendor ensures that it’s downstreamvendors that receive material as part of VH Techworks, LLC    downstream recycling chain adhere to these requirements.

5.   Focus Materials that are exported are transported instrict adherence to applicable legal requirements and Provision 3(a)(2) of the R2 Standard.

6.   For any Focus Materials or items that contain FocusMaterials that are reused they are handled in accordance to Provision 6 of the R2 Standard.

7.   The downstream vendor maintains for at least threeyears commercial contracts, bills of lading, or other commercially-accepteddocumentation for all material shipments.

Form Completed By:

Management Representative:

VH Techworks