ATTACHMENT E: Worksheets for Evaluation of Criteria for Approval

This attachment contains the following sections:  
•	GEMS Permit Worksheet for Evaluation of Criteria for Approval
•	Custom Waiver Permit Worksheet for Evaluation of Criteria for Approval

GEMS Permit Evaluation Worksheet

Facility Name:		Green Permit No.:	
Lead Agency:  _______________________________________________
Team Leader:  _______________________________________________
Other Agencies					Other Team Members

					

1.	Type of GEMS Permit Applied for: 
	 GEMS Participant Permit       GEMS Achiever Permit         GEMS Leader Permit
2.	Has the environmental management system been certified by a third party, such as certification to the ISO 14001 environmental management system standard?  Yes   No
If yes, when was the certification achieved?		

	REQUIREMENT	EVALUATION	
 3.	If the environmental management system has not been certified by a third party, does it meet the expectation for a:  (check one)
__  Basic EMS (Participant Permit), or
__  ISO-Comparable EMS (Achiever or Leader Permit)?
(Note: Use the attached EMS verification worksheets to help evaluate this section.  It may be helpful to list the number of each assessment rating from the worksheet in the appropriate column to determine your overall evaluation.)  	YES	NO	DK	
	Comments:		

4.	As part of the environmental management system, did the facility commit to maintaining and exceeding regulatory compliance, commit to applying the pollution prevention definition and hierarchy when setting objectives and targets and developing the environmental program, and commit to continual improvement?	YES	NO	DK	
	Comments:		

 5.	As part of the environmental management system, did the facility evaluate environmental aspects, and set objectives and targets for significant environmental impacts?  	YES	NO	DK	
	Scope of objectives and targets: 						
	Comments:		
					
 6.	Did the facility establish an environmental program that will achieve results significantly better overall than otherwise required by law? 	YES	NO	DK	
	Comments:		
					
 7.	Did the facility establish performance measures that explain the environmental information in context with past performance?  	YES	NO	DK	
	Comments:		
					
 8.	Did the facility develop and submit a baseline environmental performance report, that includes:  (check all that are included)	YES	NO	DK	
	•	The environmental policies affecting the facility’s operations;				
	•	information regarding significant environmental impacts;				
	•	A description of the environmental program that will achieve results that are significantly better overall than otherwise required by law;				
	•	For existing facilities, a demonstration that the facility has reduced overall impacts in the three year period  prior to applying for the GEMS permit (Achiever and Leader Permits only);				
	•	For new facilities, a description of the methods used to minimize environmental impacts in the design of the facility (Achiever and Leader Permits only);				
	Comments:		

 9.	Did the facility develop a plan for updating the environmental performance report?  The report should include at least the following information:  	YES	NO	DK	
	•	Update of environmental policies;				
	•	Update of information regarding significant environmental impacts;				
	•	Performance achievements, and if appropriate, a description of any obstacles encountered and how addressed; 				
	•	EMS deficiencies experienced during the past year, and how addressed;				
	•	Compliance issues experienced during the past year, and how addressed;				
	•	Stakeholder involvement activities during the past year, input received and how addressed;				
	•	Revised objectives and targets for targeted environmental impacts				
	Comments:		
					
10.	Did the facility develop a Stakeholder Involvement Plan that:   	YES	NO	DK	
	•	Is appropriate to the scope of the EMS and established objectives and targets, and				
	•	Includes a mechanism for receiving, considering, and responding to comments received?				
	Comments:		
					
11.	Has the facility begun implementing its Stakeholder Involvement Plan, including mechanisms for receiving and responding to comments, considered results of stakeholder involvement in decision-making, and responded to comments received?  	YES	NO	DK	
	Comments:		
					
12.	Has the facility encouraged public inquiries and comments regarding the facility’s environmental performance, and provided mechanisms to discuss the environmental policy, annual performance report, environmental aspects and impacts, and establishment of objectives and targets?  	YES	NO	DK	
	Comments:		
					
13.	Has the agency received any complaints from any stakeholders regarding the stakeholder involvement process?  	YES	NO	DK	
	Comments:		
					
14.	Is the description of the environmental performance included in materials distributed to the stakeholders consistent with information verified by DEQ?  				
	Comments:		

15.  What waivers or incentives have been requested by the facility?  

Description of Waiver or Incentive Requested	Permit Condition or Regulatory Requirement Citation	Agency responsible, and status of incorporation into the draft permit	

			

			
16.	Is the waiver no more than two times the length of the period that would otherwise be required by law?  Yes   No
17.	For GEMS Achiever and GEMS Leader Permits, what length of renewal period was requested?  
(maximum ten years) 		
18.	Does the facility meet the criteria for approval of the requested GEMS Permit? 
 Yes   No   Needs Improvement
If no or needs improvement, does the facility meet the criteria for approval of a different type of GEMS Permit?  Yes   No   
If yes, what type of GEMS Permit?		
19.	
Additional comments:		

	

Name of Agency Verifier:		
Signature of Agency Verifier:		
Date Completed:		

Custom Waiver Permit Evaluation

Facility Name:			Green Permit No.:		
Lead Agency:  _______________________________________________
Team Leader:  _______________________________________________
Other Agencies					Other Team Members

					

	REQUIREMENT	EVALUATION	
 1.	Did the facility demonstrate that the waiver is needed to achieve the desired results?  	YES	NO	DK	
 2.	Did the facility provide technical information or the scientific basis for the predicted results?  	YES	NO	DK	
3.	Did the facility provide information that demonstrates the facility will be able to monitor, assess and manage the environmental impacts related to the custom waiver?  	YES	NO	DK	
	Comments:		
					
4.	Did the facility develop a Stakeholder Involvement Plan that:   	YES	NO	DK	
	•	Is appropriate to the scope of the Custom Waiver, and				
	•	Includes a mechanism for receiving, considering, and responding to comments received?				
	Comments:		
					
5.	Has the facility begun implementing its Stakeholder Involvement Plan, including mechanisms for receiving and responding to comments, considered results of stakeholder involvement in decision-making, and responded to comments received?  	YES	NO	DK	
	Comments:		
					
	REQUIREMENT	EVALUATION	
6.	Has the agency received any complaints from any stakeholders regarding the stakeholder involvement process?  	YES	NO	DK	
	Comments:		
					
7.	Is the description of the environmental performance included in materials distributed to the stakeholders consistent with information verified by DEQ?  				
	Comments:		

8.  What waivers or incentives have been requested by the facility?  

Description of Waiver or Incentive Requested	Permit Condition or Regulatory Requirement Citation	Agency responsible, and status of incorporation into the draft permit	

			

			
9.	Does the facility meet the criteria for approval of the requested Custom Waiver Permit? 
 Yes   No   Needs Improvement
10.	Additional comments:		

	

Name of Agency Verifier:		
Signature of Agency Verifier:		
Date Completed: