DOWNSTREAM VENDOR QUESTIONNAIRE
CONTACT INFORMATION
Company/Facility
Name
Stre
et
Cit
Sta
Zi
Country/Pro
y
te
p
vince
Telephon
Contact Name
e
Contact Email
Fax
Company Website
FACILITY INFORMATION
Total Employees
Size of Property/Size
of Facility
Is the facility owned
or leased?
Number of Shifts
Hours of Operations
Total sq. ft. capacity
Stora
Processin
for
ge
g
COMPANY HISTORY
Years in Operation under current owner
Current Owner/Principal
List Parent Company, if
applicable
Previous Owners and dates of
operations
MATERIALS PROCESSED/HANDLED (CHECK ALL THAT APPLY)







Batteries - Alkaline
Batteries – Lead Acid
Batteries – Lithium
Batteries – Other (List): _________________
Circuit Boards
Circuit Boards containing devices (mice, keyboards, power supplies, printers, fax machines,
other low grade electronics)
CRT or CRT Glass (monitors, televisions, equipment)





PCBs (Polychlorinated biphenyls)
Mercury
Mercury Containing devices (fluorescent tubes, laptops, LCD displays, LCD televisions)
Other (List):
Other (List): _________________
SITE HISTORY
Nature of previous business on site:
Are there any open or closed remediation projects on
the site? If yes, describe.
Note sensitive receptors within .5 miles of the facility:
Regulatory Compliance Status: Has the facility received
any financial penalties, regulatory orders or violations
within the last five years?
PROCESS INFORMATION
Describe the processes used to handle (enter your company name)’s materials:
List all materials generated by the processing of (enter your company name)’s material and the next
tier vendors used to process the material further.
Material Generated
How are the materials processed
or disposed?
Next Tier Vendor Name
and Address (Include all
tiers to end processor)
PERMITS/REGISTRATIONS/LICENSES and INSURANCE
Is the facility subject to any of the following permits, registrations or licenses? (check all that apply
and provide the permit information and agency information where available.) Please attach copies of
the permit.
PERMIT #
ISSUING AGENCY
Operational/Business Permits or
Registration
Environmental Permits
Waste Permits
Emissions to the
Atmosphere/Air Permits
Water Permits
Insurance Coverage
Workers Compensation Coverage
Please provide certificate of
insurance
Please provide certificate of
insurance
ENVIRONMENTAL MANAGEMENT SYSTEM
Does the facility have an environmental management
 YES, please attach Table of
system (EMS)?
Contents
Is the facility ISO 14001 certified?
 YES, please attach
Certificate
 NO
 NO
Does the facility have documented procedures for
identifying and complying with all applicable
environmental regulations (federal, state, county,
 YES
 NO
 YES
 NO
 YES
 NO
city and industry)?
Does the facility have a commitment to the
prevention of pollution?
Does the facility have a commitment to the
continual improvement?
Have their been any environmental regulatory
violations, fines, citations, corrective actions or
remediation against the facility?
OCCUPATIONAL HEALTH AND SAFETY MANAGEMENT SYSTEM
 YES, please attach
explanation
 NO
Does the facility have an occupational health and
 YES, please attach Table of
safety management system (OHSMS)?
Contents
Is the facility OHSAS 18001/ANZI 10 certified?
 YES, please attach
Certificate
 NO
 NO
Does the facility have documented procedures for
identifying and complying with all applicable health
and safety regulations (federal, state, county, city
 YES
 NO
 YES
 NO
and industry)?
Does the facility have annual health and safety
training for employees?
Have their been any health and safety regulatory
violations, fines, citations, corrective actions or
remediation against the facility?
 YES, please attach
explanation
 NO
Form Completed By:
Print Name:
Signature:
Title:
Date:
R2 Addendum
(Enter your Company Name) is seeking certification to R2, Responsible Recycling Practices for Electronic
Recyclers. The R2 standard identifies Focus Materials (PCBs, Mercury, CRTs and CRT glass, Batteries and
Circuit Boards) as problematic and requiring additional controls.
Your company has been identified by (Enter your Company Name) as handling/processing one or more
of (Enter your Company Name)’s focus materials. (Enter your Company Name) will be working with our
downstream vendors to pursue the following downstream vendor requirements as stated in the R2
standard (see attached R2 standard):
Selection and Ongoing Due Diligence of Downstream Vendors for FMs
For shipments of removed FMs, and shipments of equipment and components containing FMs (Enter
your Company Name) shall select downstream vendors that possess and conform to:
1. (Enter your Company Name)’s FM Management Plan,
2. A documented environmental, health, and safety management system,
3. A list of its environmental permits and copies of each,
4. Assurance that any additional downstream vendors in the Recycling Chain of (Enter your
Company Name) FMs conforms to these subsections (1) – (7),
5. If the downstream vendor is sending any of (Enter your Company Name)’s focus material for
Reuse (not recycling or recovery), they must agree to R2 Provision 6,
6. If the downstream vendor is exporting any of (Enter your Company Name)’s focus materials, they
must agree to the exporting requirements of Provision 3 (a) (2), and
7. The downstream vendor shall maintain for at least three years commercial contracts, bills of
lading, or other commercially-accepted documentation for all (Enter your Company Name)
transfers of equipment, components, and materials into and out of its facility, as well as for any
(Enter your Company Name) brokering transactions.
(Enter your Company Name) shall confirm, through audits or other similarly effective means that each
downstream vendor in the Recycling Chain to continues to conform to these requirements for as long as
it receives FMs directly or indirectly from (Enter your Company Name).
In order to comply with R2 requirements, (Enter your Company Name) is requesting all downstream
vendors sign below stating that;
1. They agree to abide by the requirements listed above;
2. They have reviewed the attached (Enter your Company Name) Focus Material Management Plan
Summary;
3. They have reviewed the attached R2 standard, if required by number 5 and 6 above
COMPANY NAME
Management Representative – Name
Title
Management Representative – Signature
Date