ARCHIRODON GROUP NV Integrated Management System

Health, Safety & Environment (HSE) Rev. Issue For Reference Serial No. Page Internal Use Only HSE-PRO-05-F07 1 of 1

FORM Monthly Environmental Monitoring Report

0.0

Section A - Water Consumption A1 Service water A2 Spraying water A3 Other A4 Total Section B - Fuel and Lubricants Consumption B1 Diesel B2 Petrol B3 Lubricants Section C - Environmental Performance Indicators C1 Disposal certificates

Unit liters liters liters liters Unit liters liters liters Number/ Quantity

Quantity

Remark

0 Quantity Remark

Remarks

Target All hazardous waste to be disposed through licensed contractors

Oil Spill Incidents-Tier 1 C2 Oil Spill Incidents-Tier 2/3

Incidents from Year commencement

(excluding reporting month)

Success rate (%) 100%

Tier 12

Success rate (%) 100% Incidents from Year commencement

(excluding reporting month)

Tier 2/3=0 Success rate (%) 100%

Chemical Spill Incidents-Tier 1 C3 Chemical Spill Incidents-Tier 2/3 C4 Environmental Toolbox talks C5 Environmental Training sessions C6 Environmental Drills C7 Drinking water analyses C8 Sea water analyses C9 Treated water analyses C10 Environmental Noise measurements C11 Measurements of atmospheric emissions C12 Other

Tier 12

Success rate (%) 100% Success rate (%) 0% Success rate (%) #VALUE! Success rate (%) #VALUE! Pass Pass Pass Pass Pass Fail 0 Fail 0 Fail 0 Fail 0 Fail 0 Success rate (%) #DIV/0! Success rate (%) #DIV/0! Success rate (%) #DIV/0! Success rate (%) #DIV/0! Success rate (%) #DIV/0!

Tier 2/3=0 4
* Insert number for current month as per training schedule * Insert number for current month as per drill schedule

100% 100% 100% 100% 100%

Completed by Job Position Name Surname Signature Date

Approved by Job Position Name Surname Signature Date

Distrabution list Job Position Name Surname