Sustainable Development Unit Pre-Assessment Survey

Integrated Assessment Process

This survey is used by the Michigan Department of Environment, Great Lakes and Energy; Materials Management Division in preparation to provide on-site technical assistance. No confidential business information or proprietary information should be provided. If you have any questions or need assistance, please contact Mr. Chris Babcock by phone at 517-599-7939 or by email at BabcockC4@michigan.gov.

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* 1. Company Overview

Company Name

Company Address

Primary Contact for the Site Visit

Title

Phone

Primary NAICS Code

Number of Shifts

Number of Employees

Square Footage of Facility

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* 2. What is your biggest challenge and how can we help?

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* 3. Company Information: Please check what information is readily available and attach.

Facility Map

Equipment Layout or Map

Process Flow Diagrams

Utility Bills (Electric and Natural or LP Gas)

Water Bills (Domestic and Production)

Waste Bills

Waste Disposal Types and Volumes

Waste Inventory Log(s)

Waste Minimization/Pollution Prevention Plan

Permits (Air, NPDES, Storm Water, Waste, Wastewater, others)

Safety Data Sheets (SDSs)

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* 4. Attach Facility Maps, Equipment Layout Maps, and/or Process Flow Diagrams

If selected in Question 3, please attach here.

PDF, DOCX, DOC file types only.

Choose File

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* 5. Attach Utility, Water, Wastewater, and/or Waste Bills

If selected in Question 3, please attach here.

PDF, DOCX, DOC file types only.

Choose File

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* 6. Attach Waste Disposal Types & Volumes, Logs, and/or Plans

If selected in Question 3, please attach here.

PDF, DOCX, DOC file types only.

Choose File

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* 7. Attach Permits and/or Safety Data Sheets

If selected in Question 3, please attach here.

PDF, DOCX, DOC file types only.

Choose File

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* 8. Tell us what your company does, including significant operations and/or processes:

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* 9. Does your facility generate any of the following waste streams?

	Yes	No
Wastewater Effluent	Wastewater Effluent Yes	Wastewater Effluent No
Air Emissions including Stack and Fugitive	Air Emissions including Stack and Fugitive Yes	Air Emissions including Stack and Fugitive No
Universal Wastes	Universal Wastes Yes	Universal Wastes No
Non-Hazardous Solid Wastes	Non-Hazardous Solid Wastes Yes	Non-Hazardous Solid Wastes No
Hazardous Wastes	Hazardous Wastes Yes	Hazardous Wastes No
Liquid Industrial By-Product	Liquid Industrial By-Product Yes	Liquid Industrial By-Product No

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* 10. Hazardous Waste Generator Status:

CESQG

SQG

LQG

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* 11. Please provide a brief description of your main waste streams, including all hazardous and non-hazardous liquids:

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* 12. Do you have preventative maintenance programs?

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* 13. Do you have any floor drains, and if so, do you know where they discharge?

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* 14. Do you have storm drains in your parking lot(s) and if so, do you know where they discharge?

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* 15. Do employees receive training on a regular basis and, if so, what kind of training?

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* 16. Does your company have a written environmental management policy?

Yes

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* 17. If Yes, please attach your written environmental management policy.

PDF, DOCX, DOC file types only.

Choose File

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* 18. Has a pollution prevention or waste minimization assessment been conducted previously

Yes

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* 1. Company Overview

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* 2. What is your biggest challenge and how can we help?

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* 3. Company Information: Please check what information is readily available and attach.

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* 4. Attach Facility Maps, Equipment Layout Maps, and/or Process Flow Diagrams

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* 5. Attach Utility, Water, Wastewater, and/or Waste Bills

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* 6. Attach Waste Disposal Types & Volumes, Logs, and/or Plans

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* 7. Attach Permits and/or Safety Data Sheets

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* 8. Tell us what your company does, including significant operations and/or processes:

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* 9. Does your facility generate any of the following waste streams?

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* 10. Hazardous Waste Generator Status:

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* 11. Please provide a brief description of your main waste streams, including all hazardous and non-hazardous liquids:

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* 12. Do you have preventative maintenance programs?

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* 13. Do you have any floor drains, and if so, do you know where they discharge?

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* 14. Do you have storm drains in your parking lot(s) and if so, do you know where they discharge?

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* 15. Do employees receive training on a regular basis and, if so, what kind of training?

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* 16. Does your company have a written environmental management policy?

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* 17. If Yes, please attach your written environmental management policy.

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* 18. Has a pollution prevention or waste minimization assessment been conducted previously

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* 19. Please describe any pollution prevention projects that you have implemented or would like to implement.