Preliminary Questionnaire for Environmental Management Systems

Complete one questionnaire for each facility to be assessed and registered.
Please complete this questionnaire in detail, attach any relevant documentation, and e-mail or fax to AIQR. Upon receipt and review of the response to this questionnaire, AIQR will provide you with a quotation and a tentative timetable for the assessment and registration of your Environmental Management System. For questions that may not be applicable to your facility or country please mark "N/A" (and provide clarifications where possible).

1. Corporate Profile

* Company Name: Site Address (es): List all sites to be included in the assessment. Are there specific field / offsite activities performed by your Company? Mailing Address: Address (cont): City: State: Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone: Number of Employees: Number of Management: Number of Office Employees: Number of Plant Employees:

2. Scope of Activities to be Registered

Describe the nature of your business operations and scope of activities: (If multiple sites list activities at each facility):

3. Environmental Management System (EMS)

Have you documented your EMS? Yes No Is your EMS Manual available? Yes No In what language is your documentation written? Is English language copy available? Yes No Is your EMS integrated with other management systems? Yes No Name of system: Do you have a Quality Management System (QMS)? Yes No Is your QMS registered? Yes No If yes, name the registrar: To which standard: Preferred dates for: Pre-assessment, (Optional): Readiness Review (Stage 1) Registration Assessment: Is AIQ your trainer? Yes No What is the name of your consultant?

4. Site / Facility Information

Please provide a brief description of your site, including relevant geological information: Can you currently provide evidence of the required compliance evaluation? Yes No If not, by when do you expect to have this completed? Does your facility have the potential for environmental emergencies? Yes No Explain: Is your facility located near a residential area, school or hospital? Yes No Is your facility close to an environmentally sensitive area? Yes No On / Near a body of water? Yes No Indicate each shift during which activities associated with significant environmental aspects are conducted (include maintenance): Total area of land taken by each site (m2): Total area of plant (m2): Total area of offices (m2):

5. Air Emissions

Does your facility produce significant noise? Yes No Please clarify: Does your facility produce significant odors? Yes No Please clarify: Does your facility produce significant odors? Yes No Please clarify:

6. Environmental Information: Please check ALL applicable information in the table below:

Potential Environmental Contaminants Store Generate Use Treat Transport Dispose Comment Biodegradable Waste Non-biodegradable Waste Hazardous waste Non-hazardous waste Flammable goods Non-flammable goods Explosive material Raw material Toxic material, waste / emissions Reactive material Liquid waste/ effluents Process contact water Non-contact process water Chemicals / herbicides Pesticides / Fungicides Asbestos PCBs Fugitive emissions Gaseous emissions Particulate emissions Hazardous Air Pollutants Heavy Metals Other (explain)

7. South & Groundwater

Does your facility have any underground water wells or water storage tanks? Yes No Please clarify: Does your facility have any underground storage tanks for chemicals / oil / gasoline? Yes No Does your facility have contaminated / untreated / treated surface water runoff? Yes No

8. General Questions

What environmental containments do you monitor? What environmental regulations apply to this site? Are there any health and safety risks that auditors should be aware of while performing the audit? In what language will the audit be conducted? Identify protective gear e.g. gas-mask, eye protection, ear protection, foot protection, gloves, head protection, that are required to be worn, by whom, where and when: How did you hear of AIQR? Your Name: Position:

*Travel expenses, food, and lodging not included in quote.