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Chapter 10: Sample Forms

Provided by the International Finance Corporation


Action Plan Emergency Plan Process Identification Plan Environmental Policy Prevention Plan Training Plan Material Identification Plan Action Plan Form (Sample) Category: Water waste Subject: Water reuse Specific objectives and targets Objective:Minimize water use however technically and commercially practical. Target:Reduce water consumption at selected sites by 15percent of present levels within one year. Action team and team leader NameDepartmentPhone Team Leader Team Member Team Leader Project stages in the life cycle of the company's products, service and activities Low Impact = L Medium Impact = M High Impact = H Classification table for degree of impact & period of occurrence: Pre-ProductionManufacturingProduction/ DistributionAuxiliary ServicesUse/ size="-1"> ServiceWaste Management WaterLHMMHH Severity of impactProbability of occurrencePotential legal exposureCost of changing the impactEffect on the public imageCost- effective benefits WaterLHLLHH Measures to eliminate or minimize the negative environmental impact Measure to reduce water consumption and monitor its use: Purchase hose guns, water meters and timer valves. Repair all leaks. Purchase equipment to allow recycling rinsing water from process A to process B. Required information and resources; action team assistants Who is responsible for searching information? Environmental Task Group - Mr. Joe Water - Project Coordinator Types of information: Consult engineering department for advice on equipment. Purchase department will search for water recycle equipment (model, specification, and price) and make arrangements for installation. Operation manager will arrange training and start-up requirements. Other sources of information: The Internet (a good searching tool) Water-related environmental agency or organization Schedule of activities, dates and deadlines Repair all leaks - 10 days - by 20/09/2001 Purchase of hose guns, water meters, and timer valves - 10 days - by 20/09/2001 Installation of hose guns, water meters, and timer valves - 20 days - by 10/10/2001 Purchase of equipment to recycle water - 30 days - 30/09/2001 Installation of equipment - 60 days - 30/10/2001 (forecast) Performance measurements Water consumption is already measured monthly. Ms. A (accounting department) will provide data to Mr. B (environmental task group) every month. Mr. C (operating department) will record gallons of water recycled during rising process and inform Mr. B (environmental task group) every month. List of expected benefits Reduction of 35 percent of water consumption cost. Saving of US₱xxxx. New equipment increased production by eight percent. Environmental friendly action - information for next marketing campaign. Payback period between two months and three years. Investment costs Provision: Equipment US₱xxxxxx Management 17 hours . Level B staff 28 hours. Date for first assessment The water consumption is monitored monthly. The results of the first six months should be compared and reviews by the environmental task group, presented to the top management and communicated to staff. Prevention Plan Form (sample) Requested Date Date for the first review to be expected NameDepartmentPhone Requested by Issued by Issued to Problem Statement Most Likely Causes Implemented Solutions (include dates as applicable) Results (confirming effectiveness) Emergency Plan Form (sample) Issue (Potential emergency situations - fires, explosions hazardous materials spills, etc.) Problem Statement Emergency Response Procedures (include communication procedures) Locations and Types of Emergency Response Equipment Evacuation Routes and Exits (map) Training Plan Form (sample) Training TopicAttendeesFrequencyProgramComments EMS Awareness Chemical Management Spill Prevention and Response Emergency Response Hazardous Waste Management Process Identification Form (sample) Comments, Suggestions and Recommendations for Improvements Receiving Storage On Site Product Design Raw Material (Substitutes / Reductions) Waste Disposal Water Use/Discharge Energy Sources/Use Solid and Hazardous Waste Emissions/Discharge Evaporation losses Maintenance losses Spills Corrosive waste Reactive waste Toxic waste Spoiled batches Packaging Transport and Distribution Site/Building Material Identification Form (sample) Process Material Used Product Name Chemical Name Amount Used Amount (gallons, lbs. or drums) used per (day, month or year) Environmental Policy (sample) An environmental policy is a unique document for each organization. The following example is intended to illustrate and provide ideas for writing an environmental policy that suits the company's commitment to environmental issues. Company X's Environmental Policy Company X is committed to a clean, healthy environment. "We will provide our customers with safe, reliable and responsive utility service in an environmentally sensitive and responsible manner. We believe that sound environmental policy contributes to our competitive strength and benefits our customers, shareholders, and employees by contributing to the overall well-being and economic health of the communities we serve." We will: Comply fully with the letter and spirit of environmental laws and regulations, and strive to secure fundamental reforms that will improve their environmental effectiveness and reduce the cost of compliance. Consider environmental factors and the full acquisition, use and disposal costs when making planning, purchasing and operating decisions. Provide appropriate environmental training for all staff. Monitor our environmental performance regularly through rigorous evaluations. Reuse and recycle whenever possible. Use environmentally preferred materials. Work cooperatively with others to further common environmental objectives. Statement of Corporate Environmental Policy Company X is committed to the continual improvement of its Environmental Management System (EMS), which includes waste minimization, pollution prevention and compliance with all relevant federal, state, and local environmental legislation and regulations. The company will meet or exceed the environmental requirements of other organizations to which Company X subscribes. To sustain this commitment, the requirements of the Environmental Management System described in our EMS Action Plan apply to all activities, equipment, material and employees. The company's Environmental Task Group is the company's EMS Management Representative, with the responsibility and authority to plan, enforce, and maintain the company's Environmental Management System. The Environmental Task Group, with the assistance of the Environmental Action Group and Audit Team, will propose annual targets and objectives to be approved by the Management Review Board. The EMS Environmental Task Group may delegate some of this authority downward through the organization in order to effectively implement the system. Signed, President and CEO(date)

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