2009 Annual
Pollution Prevention
Pledge Recertification
Reaffirm your membership! The Executive Committee of the Indiana Partners for Pollution Prevention (Partners) appreciates your cooperation in completing this survey regarding your membership in the Partners. The information you provide will be used to measure the efforts of the Partners voluntary pollution prevention program. Completing this form is required for continued membership in the Partners for Pollution Prevention.
Due July 9th, 2010
Directions: Please complete the entire survey in as much detail as possible.
· Part I, Contact Information, allows the Executive Committee to update their records to reflect any changes at your organization within the past year.
· Part II, Committing to the Partners Pledge, reaffirms your organization’s dedication to the Partners Pledge.
· Part III, Voluntary Pollution Prevention Efforts, is information the Indiana Department of Environmental Management (IDEM) will use to promote the pollution prevention (P2) projects the Partners are working on throughout the state and to report Indiana pollution prevention information to a national database. Your company’s specific name will not be used in this database. This section is an opportunity to highlight your organization and the Partners collaboratively. Information provided in this section may be included in IDEM press releases, annual reports, and websites.
· Part IV, Suggestions, will assist the Partners in making improvements to best serve your P2 needs.
If the question does not apply to your organization, please leave it blank. If you are an organization that works with facilities on pollution prevention efforts, you may include data from Indiana facilities that are not current members of the Partners for Pollution Prevention.
Questions: Contact Laura Flagg with the IDEM Office of Pollution Prevention and Technical Assistance at (800) 988-7901 or .
PART I: Contact Information
Company Name
Address
Partners Representative Contact
Name
Title
Phone Number
E-mail Address
Brief description of your facility and its operations
How many employees (full time equivalents) currently work at your facility?
< 50
50-99
100-499
500-1,000
> 1,000
Can the Executive Committee include this information in the Partners for Pollution Prevention Member Directory? The directory will be distributed to active Partners for improved networking and information sharing among members.
Yes No
If yes, the information you provide will be used to update the Partners Contact List (Executive Committee use) and the Partners Directory (distributed to all Partners).
If no, the information you provide above will only be used to update the Partners Contact List (Executive Committee use).
DO YOU WISH TO RECERTIFY Yes No (if no, please answer the following question and return the survey – Thank you)
Would you like a follow-up call to discuss your decision not to recertify? Yes No
PART II: Committing to the Partners Pledge
Please answer the questions in this section regarding your organization’s commitment to the pledge.
Yes / No1. Are employees aware of your commitment to pollution prevention and understand their role in implementing pollution prevention objectives and goals in your facility?
2. Has your organization incorporated pollution prevention planning in the development of new products, processes, and/or services?
3. Has your organization established a mechanism to monitor waste generation and identify realistic pollution prevention goals?
4. Has your organization established a process to listen and respond to stakeholder concerns?
5. Will your organization make available your general waste reduction and pollution prevention information to members of our community, IDEM, and the Partners, if requested?
6. Has your organization participated in or conducted outreach activities that include details of your pollution prevention efforts?
If yes, please specify
7. Has your organization participated in two or more Partners meetings in the last year?
In person Conference call
8. Has your organization supported the annual Pollution Prevention Conference and Trade Show? Please check all that apply.
Financial sponsorship One or more attendees from your organization
Other – specify
9. If you answered no to any of the above items, please explain below:
10. What are some barriers you encounter when considering new P2 projects? Please describe (cost, time, product quality, etc.). In what ways can the Partners or IDEM assist you?
11. Are you a member of the Indiana Environmental Stewardship Program (ESP)?
If no, would you like more information about ESP? Yes No
12. Did your facility / organization adopt or amend P2 policies this year?
13. Does your facility / organization have an Environmental Management System (EMS)?
If yes, year established:
Is the EMS ISO 14001 or third party certified?
14. Did your facility / organization develop a P2 team this year?
15. Did your facility / organization map your process/es this year?
16. Did your facility / organization see compliance improvements this year?
17. Number of employees trained in pollution prevention this year
Number of People
PART III: Voluntary Pollution Prevention Efforts
Please copy and complete this section for each P2 effort that resulted in a voluntary reduction of pollution not due to a decrease in production. This section has been modified to collect data in the format IDEM has been asked to submit it to a national database. Please include efforts such as technology modifications, material substitutions, improved housekeeping, green building practices, energy efficiency projects, recycling efforts, etc.
Please do not include information and data for projects that have been submitted to the Indiana Environmental Stewardship Program.
Non-Hazardous MaterialsProcess input supplies and feed stocks that are not toxic or hazardous. Examples include packaging, building materials, aqueous cleaners, etc.
Reduce Use / Pounds / Year
Initial Cost / Dollars
Savings / Dollars
Description
Hazardous Materials
Process input feedstock and supplies that are toxic or hazardous. Examples include chemicals, solvents, pesticides, etc.
Reduce Use / Pounds / Year
Initial Cost / Dollars
Savings / Dollars
Description
Hazardous Wastes
State and/or federally listed hazardous or toxic wastes or wastes meeting the criteria for ignitability, toxicity, corrosivity or reactivity.
Reduced Generation / Pounds / Year
Initial Cost / Dollars
Description
Air Emissions (includes mobile services)
Toxic air emissions including VOCs, HAPs, Nitrogen Oxides, Sulfur Oxides, Carbon Dioxide, PM, other air emissions.
Reduced Releases
Toxic Air / Pounds / Year (Air Emissions Reduced)
CO2 / Pounds / Year (Air Emissions Reduced)
NOx / Pounds / Year (Air Emissions Reduced)
VOC / Pounds / Year (Air Emissions Reduced)
SOx / Pounds / Year (Air Emissions Reduced)
PM / Pounds / Year (Air Emissions Reduced)
Other Air Emissions / Pounds / Year (Air Emissions Reduced)
Initial Cost / Dollars
Description
Solid Waste
Wastes other than RCRA hazardous wastes.
Reduced Generation / Pounds / Year
Initial Cost / Dollars
Description
Energy
Energy is any source providing usable power.
Reduced Use
Electricity / Kilowatt hours / Year (Energy Reduced)
Natural Gas / Therms / Year (Energy Reduced)
Vehicle Miles / Miles / Year (Energy Reduced)
Diesel / Gallons / Year (Energy Reduced)
Jet Fuel / Gallons / Year (Energy Reduced)
Coal / Tons / Year (Energy Reduced)
Other Fuels / Kilowatt hour equivalent / Year (Energy Reduced)
Initial Cost / Dollars
Description
Green Energy
Energy produced from renewable sources such as solar, wind, geothermal, low-impact hydro, and biomass.
Generation or Purchase
Solar / Kilowatt hours / Year (Energy Purchased)
Kilowatt hours / Year (Energy Generated)
Wind / Kilowatt hours / Year (Energy Purchased)
Kilowatt hours / Year (Energy Generated)
GeoThermal / Kilowatt hours / Year (Energy Purchased)
Kilowatt hours / Year (Energy Generated)
Low-Impact-Hydro / Kilowatt hours / Year (Energy Purchased)
Kilowatt hours / Year (Energy Generated)
Biomass / Kilowatt hours / Year (Energy Purchased)
Kilowatt hours / Year (Energy Generated)
BioDiesel / Gallons (Energy Purchased)
Gallons (Energy Generated)
Ethanol / Gallons (Energy Purchased)
CNG / Gallons (Energy Purchased)
Initial Cost / Dollars
Description
Water Use
Incoming raw water from outside sources for operations, facility use, and grounds maintenance.
Reduced Use / Gallons / Year
Initial Cost / Dollars
Description
Water Pollution (includes point sources, nonpoint sources and storm water)
Quantity of pollutant discharged (for example, BOD, COD, toxics, nutrients, TSS, contaminants in storm water and pathogens. Includes discharges to sewer systems, septic systems, injection wells, ground water, etc.)
Reduced Releases
BOD / COD / Pounds / Year (Pounds Reduced)
Toxics / Pounds / Year (Pounds Reduced)
Nutrients / Pounds / Year (Pounds Reduced)
TSS / Pounds / Year (Pounds Reduced)
Contaminants in storm water & pathogens / Pounds / Year (Pounds Reduced)
Initial Cost / Dollars
Description
Recycling Data
Amount of material / Pounds / Year
Initial Cost / Dollars
Description (items recycled?)
Yes / No
Can IDEM publicize this effort? (Such as through reports, websites, press releases, etc.)
Are you willing to share this P2 effort at a Partners Quarterly Meeting or at the annual P2 conference?
PART IV: Suggestions
1. What do you feel are the benefits for your organization to be part of the Partners?
Recognition from IDEM of our P2 dedication. Please describe any particular occurrence from the past year such as:IDEM Inspector saw the Partners plaque
IDEM press release, speech or publication mentioned our organization’s name in association with the Partners
Other IDEM Officials became aware of our organization’s involvement in the Partners
IDEM commissioner recognition during the P2 annual conference
Other
Positive promotion of our P2 efforts and involvement in Partners to local community, such as:
Using the Partners logo during outreach efforts to the community (on letterhead, in newspaper, in annual reports, etc.)
Mentioning our membership in the Partners to media reporters (TV, radio, newspaper, etc.)
Partners plaque visible during plant tours
Outreach activities to communities where we discuss P2 efforts and our Partners involvement
Other
Networking opportunities with IDEM representatives such as:
Through the Partners quarterly meetings Through the P2 annual conference
Other
Networking opportunities with leading P2 advocates in Indiana industry such as:
Through the Partners quarterly meetings Through the P2 annual conference
Other
Opportunity to provide input related to P2 regulatory integration during IDEM policy and regulatory initiative.
Opportunities to provide input to IDEM on projects and initiatives.
Other/Comments
2. Is the Partners group meeting your expectations? If not, please provide specific suggestions.
3. How could the Partners be more beneficial to you and your organization?
More speakers on environmental regulations affecting my organization. / Professional / scientific speakers with updates on new technologies.More success stories from companies. / Hearing from vendors with new P2 technologies.
A website linking to P2 opportunities. / More active listserv announcing P2 opportunities.
Offering Continuing Education Units for portions of the meetings. / Facility tours.
Greater regulatory commenting. / Other. Please list:
4. Do you have a success story that you would be willing to share with the Partners?
5. What other groups or organizations do you participate in that would benefit from learning about the Partners? Are there other groups we should work with to market the annual conference and trade show?
Thank you for your comments!
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