Application to Participate In

PARTICIPATION AND RENEWAL APPLICATION

Colorado Mining Association Pollution Prevention Program

For Mining and Support Industries in Colorado

For Plan Year Ending October 31, 2018

This Form is to be used to notify the Colorado Mining Association (CMA) of your intention to participate in the CMA Environmental Stewardship and Pollution Prevention Program during the period November 2017–October 2018. Members who participated previously should resubmit this form to ensure that CMA has the basis to manage the program and assist the participants. To ensure your eligibility for the 2017-2018 year, this completed form must be received by no later than November 30, 2017. Members of the program must also be current in the payment of dues to CMA for sustaining membership.

Name of Company:

Name of Operation/Facility or Office to Be Enrolled:

Company and/or Facility/Operation Name EXACTLY As It Should Appear On the Award:

Address:

Name of Company Contact:

Phone Number:

Email Address:

Signature of Company representative:

Payment of $600 (50 or more employees in Colorado) or $400 (fewer than 50 employees) must accompany application by time deadline.

Payment is attached Please charge to my credit card:

Card #

Name as it appears on the Card

Expiration Date______Email for receipt:

Visa MasterCard Discover American Express (Please Circle One)

Authorized Signature

Note:Separate applications with the fees should be submitted for geographically separated facilities operated by the same company that have geographically separated pollution prevention programs.If an applicant has more than one geographical location in Colorado and the company’s pollution prevention program integrates these, one application may be filed.

Please Send Payment to:

Colorado Mining Association

216 16th Street, Suite 1250

Denver, CO 80202

Fax:(303) 575-9194

ENVIRONMENTAL STEWARDSHIP & pollution prevention

CODE OF PRACTICES

For the mining and support industries of the State of Colorado

2017Certification Form (for November 2016-October 2017)

Operation Administrative (please  one)

Facility Name:

Facility Address:

Year first began participating in Code of Practice:

Contact Name:

Contact Title:

Contact Phone Number: Contact Fax Number:

Contact E-mail address:

Instructions for Completion of Certification Form:

A respondent may choose only to “check” the following boxes that are appropriate and to not submit any descriptive material.In most cases this, with the executed “Certification,” qualifies the respondent for listing as a Participant Member of the Pollution Prevention Program (P2) represented by this Code. Any respondent wishing to be accepted as a Senior Participant must: (1) participate in all Protocols that are relevant to their activities (2) justify non-participation in any Protocols that are deemed inapplicable and (3) explain in some degree of detail what it is that is being done to implement the applicable Protocols.Should CMA or the Colorado Department of Public Health & Environment (CDPHE), judge the responses to be lacking in justification or evidence of good-faith implementation, (a) the respondent will be notified of the apparent deficiency and (b) provided a two-week grace period to supplement the certification if the respondent wishes to request it.Those respondents fully satisfying the descriptive information requests will be accepted as fully certified Senior Participants.Further Definition of Terms and Requirements may be found at end of this Certification Form.

Applicants seeking special recognition must submit sufficient explanation and documentation of the activities qualifying for recognition under the program.For further information, see the “Description of Terms and Requirements” for special recognition at the end of this certification form.

Protocol 1.Elect to participate in the Chemical Management Protocol?

Yes No  Not Applicable: Total Partial 

If “Not Applicable” is checked, explain:

(O,A)Maintain a list of hazardous chemicals used at each facility and/or in each work area as appropriate.

Applicants for Senior Membership Follow with Explanation - Please see note #1:To better indicate the incorporation of this or an equivalent practice, please explain what is done or provide the context for a relevant attachment(s). ______.

 (O, A) A formal system exists to access current Material Safety Data Sheets (MSDS’s) for all hazardous chemicals used on-site.

Applicants for Senior Membership Follow with Explanation - Please see note #1:To better indicate the incorporation of this or an equivalent practice, please explain what is done or provide the context for a relevant attachment(s).______.

 (O)A formal program for screening hazardous chemicals prior to purchase has been implemented, which includes a mechanism for evaluating alternative products and the associated waste streams with the intent of reducing toxicity.

 (O,A)Goals have been established for this protocol, and are reviewed at least annually.Appropriate changes are made to the goals based upon these reviews.

 (O,A)Optional:Goals for this protocol include specific commitments to reduce releases of pollutants or the use of resources.Verifiable and quantifiable measures or qualitative methods exist to demonstrate progress toward goals.

Please provide specific details on goals and any quantifiable reductions or improvements (e.g. cost savings, gallons of water reduced). Goals may be stated in terms of production units.

______.

Protocol 2.Elected to Participate in the Container Management Protocol?

Yes No  Not Applicable: Total Partial 

If “Not Applicable” is checked, explain:

 (O,A)Developed and implemented a written plan to encourage bulk purchases that reduce the quantity of disposable or non-recyclable containers and packaging materials used at the facility. An employee awareness program is included in the plan.

 (O,A)Goals have been established for this protocol and are reviewed at least annually.Changes are made to the goals based upon these reviews.

Applicants for Senior Membership Follow with Explanation - Please see note #1:To better indicate the incorporation of this or an equivalent practice, please explain what is done or provide the context for a relevant attachment(s).______.

O: includes mines, mineral processing facilities, stand-alone labs, shops1

A: includes headquarters, consultants, most “support” contractors, and other stand-alone administrative facilities

Note #1. The descriptive information or attachments may address the sub-elements of each Protocol individually or in combination. However, when addressing more than one sub-element, please assist by identifying where implementation of the sub-element is specifically discussed.

Protocol 3.Elected to Participate in Conservation, Recycling, Reuse & Waste Minimization Protocol?

Yes No  Not Applicable: Total Partial 

If “Not Applicable” is checked, explain:

 (O,A)Developed and implemented a plan to review chemical and product usage andevaluate conservation, recycling, reuse and waste minimization alternatives.

 (O,A)Performed the training or other employee notification outlined in the conservation, recycling, reuse and waste minimization plan.

 (O,A)Prepared specific conservation, recycling, reuse and waste minimization goals and reviewed them at least annually. Verifiable and quantifiable measures or qualitative methods exist to demonstrate progress toward goals.Appropriate changes are made to the goals based upon these metrics and reviews.

 (O)Have developed and implemented an energy conservation program (optional participation).

 (O)Have developed and implemented a water conservation program (optional participation).

O: includes mines, mineral processing facilities, stand-alone labs, shops1

A: includes headquarters, consultants, most “support” contractors, and other stand-alone administrative facilities

PROTOCOL 4.(O) ELECTED TO PARTICIPATE IN THE RECLAMATION PROTOCOL?

Yes No  Not Applicable: Total Partial 

If “Not Applicable” is checked, explain:

 Have developed, and if appropriate, implemented a hazardous materials management plan that considers the fate of hazardous and toxic products, chemicals and wastes at time of reclamation or closure of all or part of a facility.

Have reviewed reclamation program at least annually and determined that it is achieving habitat restoration, post-mining land use and long-term sustainability in a manner that exceeds minimum regulatory requirements.

 Instituted innovative reclamation, revegetation, habitat enhancement, impact minimization or species protection project.Participation shall be of a significant level (optional participation except for Applicants for Senior Membership who must complete if applicable).

O: includes mines, mineral processing facilities, stand-alone labs, shops1

A: includes headquarters, consultants, most “support” contractors, and other stand-alone administrative facilities

Optional Protocol 5. (O)Elected to Participate in the Greenhouse Gas (GHG) Inventory

Yes No  Not Applicable 

Protocol by adopting voluntary programs and or technologies for the quantification of GHG emissions and/or reductions(Note; Electing not to participate in this protocol will not affect applicant’s qualifying as a Senior Participant).

Please describe program below and provide any relevant attachments.

______

CERTIFICATION

Facility Name: (repeat from page 1):

Time Period for which Certification applies:through

Signatures for Certification:

Senior Facility Management OfficerSenior Facility Environmental Manager

Name: ______

Signature:______

Date: ______

DESCRIPTION OF TERMS AND REQUIREMENTS

TERMS:

“Participant Member” A participant in the CMA Pollution Prevention Code of Practices that has certified its participation with completion of the Certification Form but not submitted sufficient descriptive details to allow the Certification reviewers to understand the exact planning, budgeting, and implementation procedures nor the results.

“Senior Member” A participant in the CMA Pollution Prevention Code of Practices that has certified its participation with completion of the Certification Form and has submitted sufficient descriptive details to allow the Certification reviewers to understand the exact planning, budgeting, and implementation procedures and the results.

“Criteria for Special Recognition”A Senior Member is eligible for further recognition of its“environmental management programs” as part of the CMA Pollution Prevention Code of Practices program and as part of the Colorado Department of Public Health and the Environment programs (specifically, the Colorado Environmental Leadership Program) if there is an additional demonstration of developing and meeting goals such as those outlined in the section of this Certification Form “Special Recognition and Criteria” (below).Please summarize any and all elements of the program that may qualify the applicant for special recognition.

SPECIAL RECOGNITION AND CRITERIA

The Certification Form completed by Senior Member participants will be reviewed by the CMA and the State of Colorado representatives to identify accomplishments that may merit special recognition.

Criteria for Determining Special Recognition:

While it is considered impractical to identify all criteria or factors that might be applied to determine if a reported activity is deserving of this recognition, the following criteria are examples of those that will be used:

An element of the Senior Member participant’s Pollution Program has incorporated the “local community” in a manner that multiplies its effectiveness by developing pollution prevention capabilities in the communities or region, or by finding means of accepting substances from “communities” (including local businesses) in a manner that prevents pollution.

An element of the Senior Member participant’s Pollution Program has “leveraged” more efficient pollution prevention by joining forces with other CMA Pollution Prevention participants to reduce pollution potential or resource use, or both.

An element of the Senior Member participant’s Pollution Program has incorporated an advanced technique of pollution prevention (one that is heretofore “uncommon” for the industry) that is “transferable” to other participants or potential participants in the CMA Pollution Prevention Program.

The Senior Member participant has researched and reported to the CMA Pollution Prevention Program on an element of pollution prevention in order to improve or expand or otherwise advance the Program and the report submitted either definitively justifies not pursuing the options with supporting information or recommends means of implementation.The report is for distribution to all other CMA members who have, or who may choose to have, a pollution prevention program and the topics researched or the methodology should have some application beyond the immediate interests of the respondent.