Application Form For Large And Medium Enterprises

ICC – Environment Excellence Award 2017

Application Form for Small Business Organisations (SBO) Organisations may declare a particular requirement as ‘Not Applicable’ depending on their activities (Service or Manufacturing). However, a brief explanation will be appreciated.

General Information Name of the organization

Address

Telephone .No Fax No: Website Email ID Profile of the organization and background (Please attach the profile and the Executive Summary/ profile of the Company)

Nature of the Business □ Private Ltd. □ Public Ltd. □ Partnership □ Proprietorship □ Others Type of industry: (Refer ‘Types of Industry’ in Application Guideline List)

Name of the Highest Ranking Official Designation Email Id Mobile Total Number of employees (Permanent/Contractual) Number of locations / sites Share your customer profile Last year Annual Turn Over Authorized Contact Person (Authorize a person who can answer enquiries about your organization. Questions from your Organization and requests from the Excellence Awards program would be limited to this person and the alternate identified below.) Name Designation Address Email Id Mobile No Fax No Alternative Authorized Contact Person Name Designation Address Email ID Mobile No Fax No

ICC – Environment Excellence Award 2017

Technical Information

Note: 1. Please attach the relevant supporting documents. 2. Trend of previous 5 years and a future projection need to be demonstrated by the organization for each element (where applicable).

Elements Fo Sub Questions cu Points s Poi nts 1. Validity status of the required Consent to operate from State PCB: (Attach copy)

a) Air act 1. b) Water act

Statutory Compliance c) Storage / handling /transportation/ disposal of hazardous chemicals / waste (including bio- medical waste and E-waste).

d) Compliance with the prescribed approvals / standards for - Effluents, Emissions, Hazardous /bio-medical /solid waste / E-waste. e) Details of rebate availed on water cess from pollution control Board. 2. Magnitude and nature of penalties for non-compliance with all applicable national, regional and local regulations associated with environmental issues (e.g., air quality, water quality). 3. Public complaint / litigation / legal action by the Pollution Control authorities, if any, in respect of the management of environmental issues / concerns of the industry pending or faced by the industry. If yes, please indicate briefly the position of the same. 4. Any other applicable legal requirement

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts 2. Cert (a) Details of any other awards received in the related fields of environment and sustainability. Environmental Leadership ifica tion s and Awa rds EM (a) Have management controls been implemented to reduce potential environmental impacts, P nuisances or hazards both on- and off-site and meeting Company requirements? (b) Are there controls in place as per Company requirements to prevent the pollution of storm water and non-contact cooling water, and to prevent contamination of process or sanitary wastewater? (c) Does the facility have a process in place to minimize wastewater generation? Res (a) Provide a copy of the organization’s environmental budget our ce (b) Is there a person within the organisation with responsibility for environmental issues? Allo Please give name and designation. cati on, Bud get

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts Syn (a) Innovative activities that share technology and management practices, leading to ergy sustainable development with suppliers, clients and industry in general. wit (b) Contribution of the industry / organization in socio-economic development, literacy h campaign, health-care assistance and population control stak (c) How key environmental areas for community support by the organization identified? eho lder s

1) Status of the Annual Environmental Statement: [Please indicate date of submission of the 3. last report (attach copy)]. Environmental Governance 2) Status of the Environmental Audit: Are you certified for ISO 14001:2015 / ISO 50001, if so, since when? (please attach a certificate copy) 3) Are the environmental features of the organisation reflected in its latest Annual Report and if so, from which year onwards? (Attach latest copy). 4) What are the special features of environment management in the organisation, which make it a strong applicant for the award? 5) How the environment is protected through practices that prevent products, services, facilities and operations impacting the surroundings?

4. 1. Details of Training of top management on environment appreciation and training of complete staff on Environmental awareness.

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts 2. Details of Education and training programmes conducted for employees People and Capacity building 3. Trained manpower for operation and maintenance of the treatment / disposal facilities for : a) Effluents b) Emissions c) Hazardous / bio-medical / solid waste (a) Specific Fuel consumption (Coal & Gas) 5. (b) Total energy use (from different sources – Conventional, Renewable) Program and Performance Ene (c) Total and specific Energy consumed rgy (d) Change from last year and trend for last 3 years (Last 3 year Trend) (e) Resource conservation measures to move towards renewable energy sources and energy efficiency. (f) Has an initial assessment of the workplace been documented to identify potential environmental impacts associated with energy usage and related controls? (g) Have processes to monitor and manage energy efficiency performance been implemented? (h) Has a program to ensure that equipment and processes operate at their designed energy efficiency been implemented? Wat (a) Total water use and specific water consumption er (b) Water sources significantly affected by the organisation’s use of water. (c) Water resource conservation measures introduced.

Car Your carbon risk coverage bon Total carbon emission at a scale of per unit of production (If Applicable)

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts Air Emissions to air, by type (e.g., NH3, HCI, HF, NOx, SOx and sulphuric acid mists, VOCs etc.) and nature. Total emission at a scale of per unit of production Sou (a) Total and specific raw material consumption (other than fuel and water) rce (b) Use of Recycled materials used Mat (d) Hazardous chemicals / materials used eria (e) Objectives, programmes, and targets for materials replacement (e.g., substituting ls hazardous chemicals with less hazardous alternatives)

Was Solid (a) Quantity of waste lumped underground by material type. te (b) On and off-site management type (e.g., incineration, land filling). Water (a) Discharges to water, by type (e.g., oils/greases, TDS, TSS, COD, BOD, metals and persistent (Effluent organic chemicals) and nature.

Water) Effluent discharge at a scale of per unit of production (b) Profile of water bodies into which discharges flow (e.g., ground water, river, lake, wetland, ocean).

(c) Any recycling plant or Effluent Treatment Plant (ETP) is in operation

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts Hazardous (a) Does the industry produce /generate / handle any hazardous waste? If yes, please indicate whether such waste is treated and made non-hazardous before disposal / stored at an approved site / dumped at a non-approved site / recycled or reused with or without treatment / sold to others for reuse etc.

(b) Are bulk tanks for storage of hazardous materials such that they ensure the safety of personnel and the environment?

Biomedical Are all biohazard wastes resulting from first aid procedures or other sources to minimize personnel exposure? E-waste What measures are taken to handle the E-waste generated? Inventory Is there any program to track waste generation, disposal and recycling? Reduction/ Employees’ participation in waste minimization - Quantity of waste returned to process or Reuse/ market (e.g. through recycling, reuse, or remanufacture) by type. recycling Noi (a) Is there a system to measure the ambient noise level at day and night time? se (b) Is there acoustic enclosure for DG sets installed?

Em Please indicate position of on-site environmental accidents & off-site emergency plans and erg crisis-management set-up enc (a) On-site environmental hazards y (b) Off-site environmental hazards Pre par

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts edn ess

Pro (a) Use of environment-friendly inputs / products in the manufacturing / packing / distribution duc processes etc. t (b) Development / production / consumption / distribution of eco-friendly / label products made by industry. Pro Steps taken and results obtained in respect of the following during the past one year. cess (Please indicate results in quantitative and physical terms, to the extent possible) / (a) Use / Development of clean technologies. Clea (b) Reduction in the consumption of - Water, Power (electricity/coal etc.), Raw material. n (c) Reduction in the generation of: Tec I. Effluents hno II. Emissions logy III. Hazardous / solid waste (d) Steps for reuse / recycle of waste

(e) Plantation undertaken in and around the industry locations / sites. (f) Improvement in house-keeping to make it environment-friendly. (g) Introduction of cleaner production / manufacturing / processing technologies.

Knowledge Partner ICC – Environment Excellence Award 2017 Elements Fo Sub Questions cu Points s Poi nts (h) Use of organic composting techniques for bio-degradable wastes, waste minimization and waste exchange practices

Payment Details:

Please find enclosed Cheque / Demand Draft No...... for Rs...... , drawn in favour of “Indian Chamber of Commerce” payable at Kolkata as Application Fee (non-refundable & non-adjustable).

I agree, on behalf of my organisation, to abide by the rules of the ICC – Environment Excellence Award for Excellence competition and accept that the decisions of the ICC are final. I confirm that my organisation is eligible to take part in this competition and that all information in this application and accompanying application documents are correct. I accept the timetable, the non-disclosure and confidentiality clause and fee and cost structure. Date Signature of the Highest ranking official with office seal

Knowledge Partner