Sample Forms

Action Plan Form (sample)

	Name	Department	Phone
Team Leader
Team Member
Team Leader

	Pre-Production	Manufacturing	Production/ Distribution	Auxiliary Services	Use/ Service	Waste Management
Water	L	H	M	M	H	H

	Severity of Impact	Probability of occurrence	Potential legal exposure	Cost of changing the impact	Effect on the public image	Cost-effective benefits
Water	L	H	L	L	H	H

• 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.

• Environmental Task Group | Mr. Joe Water | Project Coordinator

• 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.

• The Internet (a good searching tool)
• Water-related environmental agency or organization

• Repair all leaks – 10 days – by 20/09/2001
• Purchase of hose guns, water meters, and timer valves – 10 days – by 09/20/2001
• Installation of hose guns, water meters, and timer valves – 20 days – by 10/10/2001
• Purchase of equipment to recycle water – 30 days – 09/30/2001
• Installation of equipment – 60 days – 10/30/2001 (forecast)

• 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.

• 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.

• Provision:
• Equipment US$xxxxxx
• Management 17 hours
• Level B staff 28 hours

Prevention Plan Form (sample)

Requested Date
Date for the first review to be expected

	Name	Department	Phone
Requested by
Issued by
Issued to
Problem Statement
Most Likely Causes
Implemented Solutions (include dates as applicable)
Results (confirming effectiveness)

Emergency Plan Form (sample)

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 Topic	Attendees	Frequency	Program	Comments
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)

• 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.