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Rev. 9/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
Annual Report for Electronics Manufacturers
For Calendar Year 2014
Due January 30, 2015
Covered Device Recycling Act (CDRA – Act 108 of 2010)
This report form must be completed and submitted by each manufacturer that sold covered devices in
Pennsylvania during the 2012 calendar year.
I. Manufacturer Information
Company Name:
US Corporate Headquarters
Mailing Address:
Telephone:
City:
State:
Zip:
Website Address:
II. Contact Information
Check here if the same as the above corporate address
Name (Print):
Title:
Mailing Address:
Email:
Telephone:
City:
State:
Zip:
III. Breakdown of Weight Recycled Per Recycler
Name of Recycler
Address
[Attach additional sheets if necessary]
City/State
Pounds
Recycled/Reused
Check here if attaching additional sheets.
IV. Sales and Collection Information
Sales Weights of All Covered
Devices for 2012 (lbs.)
(From Registration Form)
Recycling Goal Approved by
Department for All Brands
for 2014 (lbs.)
Total Weight of Covered
Devices Collected and
Recycled/Reused in 2014
(lbs.)
Percent of Recycling Goal
Recycled or Reused
Note: Sales information is exempt from disclosure under the provisions of The PA Right-To-Know Law -- The Act
of February 14, 2008 (P. L. 6, NO. 3)
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V. Additional Collection Site/Event Information That Was Not Identified in the Approved Plan
If more than two collection sites or events are included here, please submit the information in spreadsheet form.
Location #1: Name of Location:
County:
Phone Number:
Address:
Types of devices collected at this location
Covered Devices Only
Covered Devices & Other e-Waste
(listed to the right)
List the method(s) used to collect covered devices at this location in the space below.
Location #2: Name of Location:
County:
Phone Number:
Address:
Types of devices collected at this location (check the appropriate box below).
Covered Devices Only
Covered Devices & Other e-Waste
(listed to the right)
List the method(s) used to collect covered devices at this location in the space below.
[Attach additional sheets if necessary]
Check here if attaching any additional sheets.
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VI. Additional Recycling Facilities That Were Not Identified in the Approved Plan
Facility #1
Name of Facility:
Permit #:
Permit Expiration Date:
Lead Contact Person:
Title:
Address:
Phone #:
City:
State:
R2 Certified?
Yes
No
Other Certification?
Yes
No
Zip:
e-Stewards Certified?
Yes
No
Name of Other Certification:
Description of the recycling processes that are used:
Will this facility transport covered devices overseas?
Yes
No
If yes, provide the following information: Name of Exporter:
Contact person at facility:
Phone Number:
Facility #2
Name of Facility:
Permit #:
Permit Expiration Date:
Lead Contact Person:
Title:
Address:
Phone #:
City:
State:
R2 Certified?
Yes
No
Other Certification?
Yes
No
Zip:
e-Stewards Certified?
Yes
No
Name of Other Certification:
Description of the recycling processes that are used:
Will this facility transport covered devices overseas?
Yes
No
If yes, provide the following information: Name of Exporter:
Contact person at facility:
[Attach additional sheets if necessary]
Phone Number:
Check here if attaching any additional sheets.
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VII.
VIII.
IX.
Rev. 9/2014
Estimate the percentage of Pennsylvanians who have access to the recycling of covered devices under
your plan.
%. Describe how this percentage was derived.
A.
Which educational methods did you utilize for notifying your customers of recycling opportunities for
your products?
Website
Toll Free Telephone Number
Product Insert
Other (describe)
B.
Were these methods effective?
C.
Do you have plans to expand your educational program, and if so, how?
Yes
No
Do you recommend expanding the program to include additional electronics devices?
Yes
No
Please justify your answer.
X.
Have all covered devices that your company manufactures been labeled with your manufacturer’s brand
whether owned or licensed?
Yes
No
If not, why not?
XI.
What methods are being used for the handling of CRT’s by your designated recyclers?
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XII.
Rev. 9/2014
Certification of Compliance
This certification is to be signed by the manufacturer who conducted a covered device collection and recycling
program in Pennsylvania during the 2014 calendar year.
By signing below, I certify that I am an authorized official of the manufacturer, have completed this form
truthfully, and the information on this form is accurate and complete and based on records maintained by
this manufacturer or manager of the manufacturer group that I participated in. In addition, I am certifying
that the manufacturer is in compliance with the requirements of Act 108 of 2010 — the Covered Device
Recycling Act. I further declare that all material will be managed at appropriately certified and permitted
electronics recycling facilities as required under the CDRA.
Signature
_________________________________________
Date
Print Name
Title
Company
Email Address
Telephone
Mailing Instructions
If by US Postal Service:
If by Ground Service (UPS, RPS, etc.)
Or Hand Delivered:
PA Department of Environmental Protection
Bureau of Waste Management
PO Box 8472
Harrisburg, PA 17105-8472
PA Department of Environmental Protection
Bureau of Waste Management
400 Market Street – 14th Floor
Harrisburg, PA 17101-8472
For Additional Information contact:
Jeff Bednar
Waste Minimization and Planning
Bureau of Waste Management
PA Department of Environmental Protection
Telephone 717-787-7382
jbednar@pa.gov
DEP website: www.dep.state.pa.us, keyword: Electronics Management, select Household
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