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1. Basic Information 项目简介

In 2010, PUMA launches the Energy Efficiency Program with ISC EHS Academy to improve suppliers energy efficiency，save costs, and advance environmental performance. As one of the key suppliers for PUMA, your inputs and support will be most important to the success of the program. We will develop the customized training materials based on this pre-survey. All the information will be handled in confidential way.

2010年 PUMA公司与美国可持续发展社区协会(ISC)及中山大学岭南学院EHS中心共同启动供应商能效管理项目，以帮助工厂提高能源效率，降低成本，提升环境绩效。作为PUMA的核心供应商，我们期待您的参与和支持。我们将根据您的意见和信息开发针对性的辅导教材。谢谢！

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* 1. Company Information 公司基本信息：

Name 公司名称:

Address 地址:

Contact 项目联系人:

Department 联系人部门：

E-mail 电子邮件:

Tel 电话：

Fax 传真:

Established in 成立年限:

Staff 职员人数:

Area 厂房面积:

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* 2. What Type of Product/s is/are manufactured in your factory? 请列出贵公司的主要产品？

A. Footwear:Shoes,Sandals 鞋类：鞋，拖鞋

B. Accessories:Bags,Balls,Caps,Eyewear,Gloves,socks,etc. 配件：箱包，球类，帽子，眼镜，手套，袜子等

C. Apparel:T-shirts,Jog Suits,Down jacket,Underwear,etc. 服装类：T恤，运动服，羽绒服，内衣等

Other (please specify) 其它（请列明）

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* 3. Who are your buyers/clients? 你公司的主要客户是？

A.PUMA only 仅有PUMA

B.PUMA and others brands 包括PUMA及其它品牌

How much of your production is for PUMA ( % ) PUMA订单占总产量的比例是多少？（%）

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* 4. Does your company have a certified/exernally verifed environment management system? Pls. indicate the certification system: 你公司是否获得得外部关于环境管理方成的认证？请列明获得的认证：

ISO14001

SA8000

OHSAS18001

Other (please specify) 其它：

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* 5. Pls. briefly introduce your produciton process & other informations here: 请简要说明你工厂的生产工艺流程及其它信息：

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* 6. Energy consumption equipment: Pls. list all your energy consumption equipment hereafter，including the name, quantity, rated capacity. etc. 请列出所有耗能设备，包括名称、数量、功率等。

Transformer 变压器

Generator 发电机

Injection 注塑机

Air conditioner 空调

Air-compressor 空压机

Boiler-diesel 柴油锅炉

Boiler-coal 锅炉（煤炭）

Boiler-electricity 电锅炉

Water-treatment 水处理设备

Furnace 熔炉

Oven 烤箱

Others 其它

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* 7. What is/are the sources of power/electricity used to run the factory operations? 贵公司的电力来源是？

A.Purchased power/grid electricity from outside 市电

B.Onsite power generation 自发电

Onsite Power generation Capacity (kVA) 自发电量

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* 8. Is there any other source of power supply? 是否有其它电力供应？

No alternative/renewable energy 没有

Solar power 太阳能发电

Wind power 风力发电

Other (please specify)其它

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* 9. Pls. list the total energy consumption volume over the past 12 months (from Sept 2009 to Aug 2010) and production waste as follows: 请列出贵公司过去12个月（2008.9-2010.8）的总能源消耗量及成本支出（采购量|总费用, 并请保留月度清单供工厂后期内部分析使用）以及生产废弃物：

Power 电 (kWh|RMB)

Diesel 柴油 (Ton|RMB)

Gasoline 汽油 (L|RMB)

Nature gas 天然气 (M3|RMB)

LPG 液化石油气 (Kg|RMB)

Coal 煤 (Ton|RMB)

Refrigerant 雪种 (Kg|RMB)

Water 水 (Ton|RMB)

Others 其它

Total production waste （1+2+3）生产废弃物总量（Ton)

1. Solid waste 固体废弃物 (Ton)

2. Waste water 废水 (Ton)

3. Hazardous waste 危险废弃物 (Ton)

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* 10. Pls. list the monthly peak and trough energy consumption volume over the past 12 months as follows: 请列出贵公司过去12个月（2008.9-2010.8）的最高及最低能源消耗量（最高值|最低值，以下各项单独统计，不必为同一个月份）：

Power 电最高值-月份|最低值-月份 (kWh)

Diesel 柴油最高值-月份|最低值-月份 (Ton)

Gasoline 汽油最高值-月份|最低值-月份 (L)

Nature gas 天然气最高值-月份|最低值-月份 (M3)

LPG 液化石油气最高值-月份|最低值-月份 (Kg)

Coal 煤最高值-月份|最低值-月份 (Ton)

Refrigerant 雪种最高值-月份|最低值-月份 (Kg)

Water 水最高值-月份|最低值-月份 (Ton)

Others 其它-月份

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* 11. Does your factory have the follow measuring & monitoring equipment/instrument?请问贵公司有哪些测量/监测仪表/工具？

照度仪 Lux meter

红外线温度计 Infrared thermometer

电测仪表 Power analyzer

压力计 Manometer

检漏计 Ultrasonic leak detector

流量计 Tachometer

燃烧分析仪 Combustion analyzer

转速表 Stroboscope

其它 Other (please specify)

1. Basic Information 项目简介

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* 1. Company Information 公司基本信息：

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* 2. What Type of Product/s is/are manufactured in your factory? 请列出贵公司的主要产品？

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* 3. Who are your buyers/clients? 你公司的主要客户是？

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* 4. Does your company have a certified/exernally verifed environment management system? Pls. indicate the certification system: 你公司是否获得得外部关于环境管理方成的认证？请列明获得的认证：

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* 5. Pls. briefly introduce your produciton process & other informations here: 请简要说明你工厂的生产工艺流程及其它信息：

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* 6. Energy consumption equipment: Pls. list all your energy consumption equipment hereafter，including the name, quantity, rated capacity. etc. 请列出所有耗能设备，包括名称、数量、功率等。

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* 7. What is/are the sources of power/electricity used to run the factory operations? 贵公司的电力来源是？

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* 8. Is there any other source of power supply? 是否有其它电力供应？

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* 10. Pls. list the monthly peak and trough energy consumption volume over the past 12 months as follows: 请列出贵公司过去12个月（2008.9-2010.8）的最高及最低能源消耗量（最高值|最低值，以下各项单独统计，不必为同一个月份）：

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* 11. Does your factory have the follow measuring & monitoring equipment/instrument?请问贵公司有哪些测量/监测仪表/工具？

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* 12. Please kindly describe the energy efficiency program(s) in your company over the past 3 years, if any. 若可能，请列举过去3年贵公司进行的节能减排的项目及成果。

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* 13. Please kindly describe your barriers and challenges on your energy efficiency program(s) in your company, if any. 若可能，请列举贵公司推行能效项目的障碍、困难。

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* 14. Please kindly describe your expectations on the energy efficiency program in next coming 12 months, if any. 若可能，请列举贵公司推行能效项目在下一年度的期望。

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If you have any question about this pre-survey, please feel free to contact us. Thank you. 若有疑问，请及时与我们联系。谢谢。

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* 1. Company Information 公司基本信息：

Question Title

* 2. What Type of Product/s is/are manufactured in your factory? 请列出贵公司的主要产品？

Question Title

* 3. Who are your buyers/clients? 你公司的主要客户是？

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* 4. Does your company have a certified/exernally verifed environment management system? Pls. indicate the certification system: 你公司是否获得得外部关于环境管理方成的认证？请列明获得的认证：

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* 5. Pls. briefly introduce your produciton process & other informations here: 请简要说明你工厂的生产工艺流程及其它信息：

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* 6. Energy consumption equipment: Pls. list all your energy consumption equipment hereafter，including the name, quantity, rated capacity. etc. 请列出所有耗能设备，包括名称、数量、功率等。

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* 7. What is/are the sources of power/electricity used to run the factory operations? 贵公司的电力来源是？

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* 8. Is there any other source of power supply? 是否有其它电力供应？

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* 10. Pls. list the monthly peak and trough energy consumption volume over the past 12 months as follows: 请列出贵公司过去12个月（2008.9-2010.8）的最高及最低能源消耗量 （最高值|最低值， 以下各项单独统计， 不必为同一个月份）：

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* 11. Does your factory have the follow measuring & monitoring equipment/instrument?请问贵公司有哪些测量/监测仪表/工具？

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* 12. Please kindly describe the energy efficiency program(s) in your company over the past 3 years, if any. 若可能， 请列举过去3年贵公司进行的节能减排的项目及成果。

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* 13. Please kindly describe your barriers and challenges on your energy efficiency program(s) in your company, if any. 若可能， 请列举贵公司推行能效项目的障碍、困难。

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* 14. Please kindly describe your expectations on the energy efficiency program in next coming 12 months, if any. 若可能， 请列举贵公司推行能效项目在下一年度的期望。

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If you have any question about this pre-survey, please feel free to contact us. Thank you. 若有疑问， 请及时与我们联系。 谢谢。

* 10. Pls. list the monthly peak and trough energy consumption volume over the past 12 months as follows: 请列出贵公司过去12个月（2008.9-2010.8）的最高及最低能源消耗量（最高值|最低值，以下各项单独统计，不必为同一个月份）：

* 12. Please kindly describe the energy efficiency program(s) in your company over the past 3 years, if any. 若可能，请列举过去3年贵公司进行的节能减排的项目及成果。

* 13. Please kindly describe your barriers and challenges on your energy efficiency program(s) in your company, if any. 若可能，请列举贵公司推行能效项目的障碍、困难。

* 14. Please kindly describe your expectations on the energy efficiency program in next coming 12 months, if any. 若可能，请列举贵公司推行能效项目在下一年度的期望。

If you have any question about this pre-survey, please feel free to contact us. Thank you. 若有疑问，请及时与我们联系。谢谢。