2520-FM-BWM0611 Rev. 8/2015 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMENT Annual Report for Electronics Manufacturers For Calendar Year 2015 Due January 29, 2016 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 2013 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 National Sales Weights of All Covered Devices for 2013 (lbs.) (From Registration Form) Recycling Goal Approved by Department for All Brands for 2015 (lbs.) Total Weight of Covered Devices Collected and Recycled/Reused in 2015 (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) -1- 2520-FM-BWM0611 Rev. 8/2015 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. -2- 2520-FM-BWM0611 Rev. 8/2015 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. -3- 2520-FM-BWM0611 VII. VIII. IX. Rev. 8/2015 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. Please explain in detail where your CRT’s are sent after collection and explain what methods are being used for the handling of CRT’s by your designated recyclers? XII. If you had a mail back program, what total amount of pounds were recycled through the mail back? How many non-mail back pounds were recycled? -4- 2520-FM-BWM0611 XIII. Rev. 8/2015 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 2015 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 -5-