FCRC Environmentally Relevant Activity Assessment Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Inspection Information

• Business

• ERA Type

• Address
  Address

• Manager/Proprietor

• Officer and Initials

• Signature

  Sign

• Rego. No.

• Inspection Type

  Routine

  Reassess

  Complaint

Issues & Examples

Air

• Dust

  Yes

  No

  N/A

• Odour

  Yes

  No

  N/A

• Light

  Yes

  No

  N/A

• Evidence of Contamination

  Yes

  No

  N/A

Water

• Bunding

  Yes

  No

  N/A

• Storm Water

  Yes

  No

  N/A

• Waste Water/Interceptors

  Yes

  No

  N/A

• Protection from Contamination

  Yes

  No

  N/A

• Evidence of Contamination

  Yes

  No

  N/A

Land

• Storage of Materials

  Yes

  No

  N/A

• Adequate Clean Up Material

  Yes

  No

  N/A

• Protection from Contamination

  Yes

  No

  N/A

• Evidence of Contamination

  Yes

  No

  N/A

Waste

• Recycling

  Yes

  No

  N/A

• Storage

  Yes

  No

  N/A

• Disposal

  Yes

  No

  N/A

Nuisance

• Complaints received

  Yes

  No

  N/A

• Evidence of Nuisance

  Yes

  No

  N/A

Dangerous Goods

• Storage

  Yes

  No

  N/A

• Protection from Contamination

  Yes

  No

  N/A

• Other comments

Signature

• The above items have been fully explained to me:

• Name

• Position

• Date

  Date

• Signature

  Sign