DOCUMENT QU1E-I

ISSUE 1 REV.9
Please complete and return this questionnaire to the address indicated below.

To : SGS Indonesia
Cilandak Commercial Estate #108 C Jl. Raya Cilandak KKO Jakarta 12560
Phone : (62-21) 781 8111
Fax : (62-21) 780 7914
E-mail : karina.primalia@sgs.com
Website : www.sgs.co.id

MANAGEMENT SYSTEMS CERTIFICATION QUESTIONNAIRE

Please fill in this questionnaire in detail and attach any relevant supporting information describing the Company’s scope of operation, e.g.
Company brochures or publicity material. On receipt of the completed questionnaire, SGS Indonesia will prepare and submit a formal
proposal on assessment cost.

A.GENERAL INFORMATION
1. Company Name : PT VARIA USAHA BAHARI

2. Address : 171 A VETERAN, GRESIK,EAST JAVA

3. Business Phone : (0356) 411855

4. Business Fax : (0356) 411744

5. Website : www.silog.co.id

6. Contact Person/ Company : 08123068264

Representative

7. Function : PORT TERMINAL SERVICE

8. E-mail Address : vuba@silog.co.id

9. Managing Director : KUKUH GAYUPRASETYO

10. Is the business already registered? (Please tick as appropriate)

 ISO 9001:2008  ISO 14001:2004  OHSAS 18001:2007  Other (Please specify)
 ISO 9001:2015
 ISO 14001:2015

Registrar/ Certification body :

Scope :

If registered by SGS, please state the : ………………………………………………………

certificate number

B. SPECIFIC CERTIFICATION QUESTIONS

1) To which part of standard is it intended to obtain registration?
Tick appropriate box
ISO 9001:2008 ISO 14001:2004 OHSAS 18001:2007
ISO 9001:2015 ISO 14001:2015 Others .......................

2) Please describe the products, processes and /or services, which is intended to include within the scope of registration.
IMPORTANT: The information provided would be used to define your Company’s scope of registration and will appear n the

- Product ………………………………………………………........................................................................
- Process / or Company : Operating Process (Sales of Port Service, Port Pilotage, Cargodoring Operation, Stevedoring
Operation)
Holding (SILOG) : Purchasing, Human Resource Management, Accounting, finance, Legal,
Maintenance
- Service : Port Pilotage Service, Stevedoring Service, & Cargodoring Service
Note : The scope of registration is directed for operation process in the head office, include for branch office
.

PT. SGS INDONESIA Systems & Services Certification Cilandak Commercial Estate # 108C, Jl. Raya Cilandak KKO. Jakarta 12560

Member of the SGS Group (Société Générale de Surveillance)

 3) What is the total number of employees in the business to be registered?
28
4) Where multiple shifts operate, please indicate shifts and number of employees

Detail For Current Scope :

Total Employee 28
Employee in Shift 12
Employee non Shift 16
No of Shift -
Shift 1 -
Shift 2 -
Shift 3 -
Skill Empl (Engineer, QA,QC dll) -
Unskill Empl (Cutting, packing dll) -

Detail For Extension to Scope Only :

Total Employee -
Employee in Shift -
Employee non Shift -
No of Shift -
Shift 1 -
Shift 2 -
Shift 3 -
Skill Empl (Engineer, QA,QC dll) -
Unskill Empl (Cutting, packing dll) -

5) Where multiple locations / site will be included into your scope of certification, please indicate total and detail
locations.

If additional sites, please provide details; Products or activities # of staff Documentation at this
site/company name and address. site same as the main
office? .same
system ?
1 Central office : Sales of Port Service, Port 7 Documentation as the
171 A Veteran, Gresik,East Java Pilotage, Cargodoring Operation, main office
Stevedoring, Operation,
Maintenance of Heavy
Equipment & Truck
2 Branch office : Sales of Port Service, Port 21 Documentation as the
171 A Veteran, Gresik,East Java Pilotage, Cargodoring Operation, main office
Stevedoring, Operation,
Maintenance of Heavy
Equipment & Truck

6) Is there any specialist operations or services carried out by a sub contractor / outsource?
Please describe : ……………………………………………………….......................................................................
……………………………………………………….......................................................................................................
7) Is there any consultant use in establishing / implementing / maintaining / evaluating of management system?
Please describe :……………………………………………………….......................................................................
……………………………………………………….........................................................................................................

C. SPECIFIC EMS CERTIFICATION QUESTIONS

1) Has a preparatory environmental review ( initial audit ) been recently performed?

Yes / No / Not Applicable
If “ Yes “ the expertise was provide from?
Corporate / Business Unit. / Consultant
2) Was the business environmental policy written after preparatory environmental review (initial audit )?
Yes / No / Not Applicable
3) If “ No” or “ Not Applicable “ answers given to question number 1 and 2 above, please explain :
………………………………………………………....................................................................................................
……………………………………………………….......................................................................................................
4) Applicable Legal and Regulatory Requirements

Emission to Air Emission to Land

Emission to Water Hazardous Waste

Non-Hazardous Waste Other, Please describe :............................

Natural Resource Usage

5) Monitoring and Measurement

a. Is the business measuring any emissions to atmosphere? Yes/ No / Not Applicable
If “Yes” for what ..................................................................................................................................................
b. Is the business measuring for anything in plant effluent? Yes/ No / Not Applicable
c. If “Yes” for what .................................................................................................................................................

6) Key Environmental Aspect relevant to the client business

Please put tick mark as appropriate
A. Air Pollution

Emissions to air from combustion of fossil fuels (energy use / vehicle use)

Release of ODS & F gases

Emissions to air - SOx, NOx, COx from large scale combustion processes

Emissions to air - particulates / dust including fugitive emissions

Engine emissions to air - road transport, aircraft, marine

Emissions to air - other emissions for example mercaptans, amines, metals, (including Hg, Cd)
H2S, halogens, Dioxins & furans etc

Emissions to air - VOC

Emissions to air - land fill gas / methane

Emissions to air - radioactive isotopes

B. Water Pollution
Discharge of 'domestic' waste water to sewer

Discharge of industrial effluent to sewer (low pollution potential)

Surface water run-off (low pollution potential)

Water pollution - suspended solids

Water pollution - COD, BOD

Water pollution - slurry, fertilizers, pesticides, dyes

Water pollution metals, CN, acids, alkalis

Water pollution - Oil / fuel / hydrocarbons

C. Waste Management
Handling, storage and off site disposal of non-hazardous waste

Handling storage and off site disposal of hazardous waste (low hazard, low concentration, small
 volumes) e.g. waste oil / oil contaminated materials, WEEE, Fluorescent tubes

Packaging waste

Waste - animal / animal by-products / clinical

Waste - toxic metals / sludge containing heavy / toxic metals

Waste oil / oil contaminated materials, solvents & other organics

Hazardous Wastes - Other chemical wastes such as sulphur & phosphorus compounds , organo-
chlorines, organo-metallics pesticides etc

Waste – asbestos

Waste - radioactive

D. Land Contamination
Soil contamination airsing from minor oil / chemical spillages

Planning / land use

Soil erosion

Land contamination

E. Natural Resource Usage

Small - medium scale consumption of gas, electricity, water and fuel

Reduction, reuse and recycling of resources

Natural resources usage - minerals / metal ores

Natural resource usage - timber / paper products

Natural resources - high consumption of electricity

Natural resources - high consumption of natural gas

Natural resources - high water consumption

Natural resources - high consumption of fuel / oil

F. Other

Local and community related issues eg noise, odour etc

Impact on ecosystems and aquatic ecosystems

Visual impact

Odour

Sustainability in construction design

Noise and vibration from blasting and demolition

Noise from plant & equipment

Noise - aircraft

Indirect impact of investment in environmentally sensitive activities or areas

Indirect impact of decisions by national / local government / public authorities

D. SPECIFIC OHSAS CERTIFICATION QUESTIONS

1) Have formal risk assessments been carried out?

.............................................................................................................................................

2) Applicable legal and regulatory requirements?

...........................................................................................................................................
3) Do you have/use/perform any of the following items/activities or have any of these hazards?
1 Steam boilers/receivers 17 Offshore operations
2 Compressed air 18 Docks
3 Lifting equipment 19 Maritime operations
4 Ionising radiation 20 Explosives
5 Abrasive Wheels 21 Transport of dangerous materials
6 Liquefied Petroleum Gas (LPG) 22 Road Haulage
7 Railways 23 Asbestos removal/Disposal
8 Lead/Other Heavy Metals 24 Woodworking
9 Pressurised Systems 25 Construction/Building
10 Diving 26 Electrical Plant/Equipment
11 Pesticides/Herbicides/Biocides 27 Gas safety/appliances
12 Food Preparation/Processing 28 Toxic Waste Treatment/Disposal
13 Machine Tools 29 Manual Handling
14 Armaments/Weapons 30 Genetically Modified Organisms
15 Agricultural Processes/equipment 31 Working at heights/depths
16 Noise 32 Other : ..........................................................................

C. EXPECTED AUDIT DATE

1 When do you anticipate to be audited?

□ Pre Audit Date :-

□ Stage 1 Audit Date : 26 Februari 2019
□ Stage 2 Audit Date : 12 Maret 2019

Date : 06 November 2018

Name : Kukuh Gayuprasetyo
Position : Direktur
Signed :