Environmental Protection Standard for Facility Issue: August 20, 2010

Form

Form

Application for Exclusion from Structural

Requirements for Environmental Facility
To Be Completed by the Applicant Division.

Date Submitted (Day/Month/Year):

Submitter’s
Name and Department:
Signature:
Division Head’s Signature:

I hereby request permission for exemption from structural requirements pertaining to the following
environmental facility.

Facility:
Purpose of
use :
Installation Location:
Reason for Exemption:

Possible risks to the environment:

(e.g. Leakage,)

Environmental Risk reduction measures to be taken:

Remarks:

* * * * * * * * * * * * * * * ** * * * * * * ** * * * * * * ** * * * * * * ** * * * * * * * * * * *
Notification
This is the reply to the above application for exemption from structural requirements pertaining to
environmental facility.

Your application has been Approved Rejected by Division President.

Date:
(Signature) (Day/Month/Year)

*This approval shall expire 2 years from the date of approval. If it is necessary to continue the
exclusion, the applicant shall apply the exclusion again by using this form for re-examination within
2 years.

[Example of Document flow] Applying department Dept. Manager Head of the Facility Division President Head
of the Facility Dept. Manager Person in charge of application (keep a copy) submit the copy to the Persons in
charge of environmental protection of Division HOYA Group Director for EP, Occupational Safety and Health