I So 14001 Gap Analysis Toolkit

EMS Gap Analysis Questionnaire
Please return a hard copy of this questionnaire to __________________________________ at ___________________________________ OR Email electronic copy to
___________________________________ at ___________________________________ by 00/00/00.
Name: Area:
Title: Facility Name:
Phone: Facility Type:
Roles and Responsibilities:
Conducting the EMS Gap Analysis
Objectives
This is a controlled document DO NOT reproduce or distribute. Draft 2008 PPI 1

The ISO 14001 Standard is internationally recognized and used by industry and government organizations to enhance environmental and operational effectiveness, efficiency,
and performance. Conducting an EMS gap analysis is a key step in developing and implementing an ISO 14001 EMS. The objectives of this step include:
Assisting select Areas and facilities in determining how their environmental management system compares to the 17 elements of the ISO 14001 EMS Standard, and
Improving EMS assessment tools and guidance to ensure practicality and compliance with environmental requirements and other relevant requirements.
Gap Analysis Background

The EMS gap analysis is a self-evaluation. A series of questions will help you compare your organizations current environmental management practices against the ISO 14001
Standard. This comparison provides a baseline assessment of your organization and helps you to identify current systems in place for managing environmental issues, including
existing policies and procedures, roles and responsibilities, communication systems, training programs and others. As you conduct the analysis, you will recognize strengths and
weaknesses of your organizations present environmental operations and determine the extent to which your operations conform to the ISO 14001 EMS Standard.
Upon completion of the analysis, you should be able to identify which of the 17 EMS elements are already in place and which you need to develop or further refine. Conducting
the gap analysis will also help familiarize you with the ISO 14001 EMS Standard and the elements critical to developing, implementing, checking, and improving the EMS on a
continual basis.
Gap Analysis Questionnaire Description and Directions

The EMS Gap Analysis Questionnaire is a tool to help you conduct an EMS gap analysis assessment on your organization. When undertaking this assessment, include people
who have direct knowledge of as many environmental and operational functions as possible. This is important so that several employees gain exposure to the EMS process and
also because each employee brings specific knowledge about environmental practices from his or her functional area.
The questionnaire first asks for basic organizational information and background information about the respondent who will be completing the survey such as name, title, roles
and responsibilities, and telephone number.
The bulk of the questionnaire addresses the ISO 14001 requirements. There are 17 short sections of questions that correspond to the 17 EMS elements. The 17 sections fall
under the five main EMS categories of environmental policy; planning; implementation and operations; corrective action; and management review. Each of the sections are
labeled with the EMS element number so you can easily reference additional information about the 17 elements of the Standard.

There are three check boxes to the right of each of the questions on the Gap Analysis Questionnaire. After you respond to each question, place an "X" or a check in the block that
best describes the status of the component as it relates to your EMS. The status blocks in the gap analysis tool are represented as follows:
Status
Not in place Partially in place In Place
X
A numerical rating measuring your organizations conformance to the ISO 14001 Standard is determined from the responses on this questionnaire. A numerical rating is given
for each component response as follows:
Not in place = 0 points Partially in place = 1 point In place = 2 points
The responses are totaled for the entire questionnaire resulting in your score. The highest score possible, 172, indicates all components of the 17 elements are In place in your
EMS (85 questions/components x 2 points for each component In place = 170 points). This baseline assessment enables you to focus on continual improvement. In the
electronic version of the EMS Gap Analysis Questionnaire provided with the EMS Toolkit, the second tab titled "Summary Chart", contains a bar chart to give you a visual
depiction of the degree to which you conform to the ISO 14001 EMS Standard. This chart can be used in management presentations to show the progress of your EMS
implementation.
Hints
1) List of Required Documentation and Records: The ISO 14001 EMS Standard requires physical (or electronic) evidence of certain documents and records. This includes,
for example, the organization's environmental policy. There is a list at the end of this gap analysis questionnaire that highlights which items require physical (or electronic)
evidence in the form of documentation or records. The list is organized by each of the 17 elements in the Standard. Elements of the ISO 14001 EMS Standard that require
documentation are indicated in bold text in the gap analysis questionnaire for easy reference to the requirements of the Standard.
2) List of Reference Material: The second part of the list at the end of this gap analysis questionnaire is a list of reference materials you may already possess that could help
you identify your current EMS status. This list is organized by each of the 17 elements of the Standard.
Question Category: Environmental Policy

EMS Element 1: Environmental Policy (ISO 14001:2004(E), Paragraph 4.2)
Status
Finding / Corrective
Indicators of Conformity Not in Partially In Notes
Action
place in place place
1. Has top management defined the organization's environmental policy?
2. Does your procedure (process) for the environmental policy ensure that the
policy is appropriate to the nature, scale and environmental impacts of its
activities, products, and services that are within the defined scope of your
environmental management system?
3. Does your environmental policy within the defined scope of your EMS
commit to continual improvement and prevention of pollution?

4. Does your environmental policy within the defined scope of your EMS
commit to complying with applicable environmental legal requirements and
other environmental requirements?
5. Does your procedure (process) for the environmental policy provide a
framework for setting and reviewing environmental objectives and targets?
6. Does your procedure ensure that the environmental policy is
documented, implemented, and maintained?
7. Does your procedure (process) for the environmental policy communicate
the policy to all persons working for or on behalf of the organization?
8. Does your procedure (process) for the environmental policy make the policy
available to the public?
Is the policy consistent with
other corporate policies
affecting the business?
Status subtotals: 0 0 0
Status Total: 0 16 points available
Percentage complete: 0
Question Category: Planning
EMS Element 2: Environmental Aspects (ISO 14001:2004(E), Paragraph 4.3.1)
Status
Action
9.
Does your procedure (process) for environmental aspects address:
Identifying environmental aspects of activities, products, and services within
the defined scope of the EMS that it can control and those which it can
influence taking into account planned or new developments, or new or
modified activities, products and services?
10. Determining those aspects that have or can have significant impact on the
environment?
11. Maintaining a documented up-to-date list of all aspects including
those that are significant?
12. Ensuring that significant environmental aspects are considered in
developing, implementing and maintaining the EMS?
Is there a risk assessment
process to determine
significance or priority of
identified environmental
aspects/impacts?
EMS Element 3: Legal and Other Requirements (ISO 14001:2004(E), Paragraph 4.3.2)

Status
Action
13. Does your procedure (process) for environmental legal and other
environmental requirements address:
Identifying applicable legal requirements related to your organization's
environmental aspects?
Accessing applicable legal requirements related to your organization's

environmental aspects?
Determining how the legal requirements apply to your organization's
aspects?
Identifying other environmental requirements to which your organization
subscribes?
Accessing other environmental requirements to which your organization
subscribes?
Determining how other environmental requirements to which your
organization subscribes apply to your organization's aspects?
14. Does your procedure ensure that environmental legal and other
environmental requirements to which the organization subscribes are
considered in developing, implementing and maintaining your organization's
EMS Element 4: Objectives, Targets and Programme(s) (ISO 14001:2004(E), Paragraph 4.3.3)
Status
Does your procedure (process) for Objectives, Targets and Programmes Indicators of Conformity Notes
Not in Partially In Action
address: place in place place
15. Establishing and maintaining documented environmental objectives
and targets at relevant functions and levels within the organization?
16. Establishing measurable objectives and targets, where practicable, that are
consistent with the environmental policy, including the commitments to
prevention of pollution, compliance with legal and other environmental
requirements and continual improvement?
17. The legal and other environmental requirements, its significant

environmental aspects, its technology options and its financial, operational
and business requirements and the views of interested parties when
establishing and reviewing objectives and targets?
18. Does your procedure (process) address establishing and maintaining

programs for achieving your organization's objectives and targets, including
designating responsibility for achieving objectives and targets at relevant
functions and levels of your organization?

19. Does your procedure (process) address establishing and maintaining
programs for achieving your organization's objectives and targets, including
the means and time-frame by which the objectives and targets are to be
achieved?
Have specific environmental
improvement objectives been
communicated to all relevant
business units and
employees, contractors and
suppliers?
Determine whether the

facility has prepared and
implemented sufficient
written policies and
procedures to ensure
compliance with applicable
standards and consistency in
implementation practices,
and to provide guidance on
how to meet applicable
standards.
Confirm that the

facility has established
compliance standards to
be followed that are
reasonably capable of
reducing the prospect of
criminal conduct.
Verify, where possible,

that the facility has taken
steps to achieve
compliance with its
environmental
standards.
Verify that the facility has a

program in place to review
the full range of capital
projects, maintenance
modifications, process
changes, and R&D initiatives
to identify potentially
significant consequences.

Determine if these
review are performed in
a timely manner, by
appropriately trained
professionals and if a
formal methodology is
employed.
Question Category: Implementation and Operation
EMS Element 5: Resources, roles, responsibility and authority (ISO 14001:2004(E), Paragraph 4.4.1)
Status
Does your procedure (process) for resources, roles, responsibility and authority Indicators of Conformity Not in Partially In Notes
Action
20. Management ensuring the availability of resources (human resources &
specialized skills, internal infrastructure, technology and financial
resources) essential for the implementation and control of the
21. Defining, documenting and communicating the roles, responsibilities

and authorities to facilitate effective environmental management?
22. Top management appointing a specific management representative who,

irrespective of other responsibilities, has defined responsibilities and
authority for:
Ensuring that an environmental management system is established,
implemented, and maintained in accordance with the requirements of ISO
14001?
Reporting on the performance of the environmental management system
to top management for review and as the basis for improvement?

Verify if the roles and
responsibilities cover:
Legal/regulatory tracking;
Updating/reviewing
documentation control
procedures; Training; Policy
and procedure development;
Contractor oversight; Follow-
up to
inspections/audits/periodic
reviews; Updating the
environmental policy;
Identifying environmental
aspects/impacts of on-site
operations; and, Responding
to external requests for
information.
Verify that the roles are

clearly defined, documented,
and understood and that
there are no redundancies or
gaps in the coverage.
Interview staff from various

operating departments to
confirm that environmental
roles and responsibilities are
clearly understood within the
facility.
EMS Element 6: Competence, training and awareness (ISO 14001:2004(E), Paragraph 4.4.2)
Status
Does your procedure (process) for competence, training and awareness Indicators of Conformity Not in Partially In Notes
Action
23. Identifying training needs to ensure that any person(s) performing tasks on
the organization's behalf that have the potential to cause (a) significant
environmental impact(s) identified by the organization is/are competent on
the basis of appropriate education, training, or experience?
24. Identifying training needs associated with the organization's environmental
aspects and its EMS? Providing training or taking other actions to meet
these needs?

25. Making persons working for the organization or on its behalf aware of:
The importance of conformity with the environmental policy and
procedures and with the requirements of the environmental management
system?
The significant environmental impacts, actual or potential, of their work

and the environmental benefits of improved personal performance?
Their roles and responsibilities in achieving conformity with the
environmental policy and procedures and with the requirements of the
environmental management system, including emergency preparedness
and response requirements?
The potential consequences of departure from specified operating
procedures?
The scope of training
includes: Emergency
response and preparedness;
The importance of complying
with established performance
criteria and the potential
consequences of departure
from specified environmental
operating procedures;
Adequate detail to motivate
personnel to prevent, detect,
and correct violations; and,
The facility offers all staff an
opportunity to attend internal
environmental training
sessions.
Identify a sample of facility

personnel who perform tasks
that can cause significant
environmental impact.
Verify that these staff

members have received
appropriate
environmental training
relative to the job
functions/tasks
performed.

Confirm that the facility
promotes environmental
awareness through periodic
memoranda, use of bulletin
boards, environmental
newsletters, award
Confirm
programs, whether
etc. staff with
environmental
responsibilities have the
relevant background,
training, and capabilities to
effectively carry out their
responsibilities.
EMS Element 7: Communication (ISO 14001:2004(E), Paragraph 4.4.3)
Status
Does your procedure (process) for Communication address: Action
26. Establishing and maintaining procedures for internal communication
between the various levels and functions of your organization with regard to
your organization's environmental aspects and environmental management
system?
27. Establishing and maintaining procedures for receiving, documenting, and

responding to relevant communication from external interested parties with
regard to your organization's environmental aspects and environmental
management system?
28. The organization's decision on whether to communicate externally on
its significant environmental aspects and the documentation of that
decision?
If the decision is to communicate externally on its significant environmental
aspects, does the organization have a method(s) for this external
communication?
EMS Element 8: Documentation (ISO 14001:2004(E), Paragraph 4.4.4)
Status
Action
29. Does your environmental management system documentation
include:
An environmental policy, objectives and targets for your
organization?

- a description of the scope of the environmental management
system?
A description of the main elements of the environmental
management system and their interaction and reference to related
documents?
Documents and records required by the ISO 14001 Standard (at
minimum those bolded in this gap analysis tool)?
Documents and records the organization determined necessary to
ensure the effective planning, operation and control of processes that
relate to its significant environmental aspects?
EMS Element 9: Control of Documents (ISO 14001:2004(E), Paragraph 4.4.5)
Status
Action
30. Does your document control procedure(s) address the need to control
documents required by the environmental management system and by the
International Standard?
31. Does your document control procedure(s) address the need to:
Approve documents before they are issued?
Review and update them as necessary, and re-approve them before
reissuing them?
Ensure changes and the current revision status of documents are
identified?
Ensure current documents are available at points of use?
Ensure documents are legible and easily identifiable?
Ensure that external documentation you deem necessary for the planning
and operation of the environmental management system are identified and
their distribution controlled?
Ensure obsolete documentation is not unintentionally used?
Identify obsolete documentation if it needs to be retained for any
purpose?

Evaluate whether: There are
systems in place to ensure
that all required reports are
sent to regulators in a timely
fashion; The
documentation/records
system clearly identifies the
maintenance retention
period, and disposition of
records; and, Employees
have access to
environmental documents
they need to conduct job
activities.
EMS Element 10: Operational Control (ISO 14001:2004(E), Paragraph 4.4.6)
Status
Does your procedure (process) for Operational Controls: Action
32. Identify those operations that are associated with the identified significant
environmental aspects consistent with your organization's environmental
policy, objectives and targets?
33. Establish and maintain documented procedures to control situations
for those operations where absence of documented procedure(s)
could lead to deviation from your environmental policy, objectives and
targets?
34. Plan these operations in order that they are carried out under specific
conditions, stipulate operating criteria, establish, implement and maintain
environmental procedures related to goods and services used by the
organization and communicate applicable requirements to suppliers and
contractors?
EMS Element 11: Emergency preparedness and response (ISO 14001:2004(E), Paragraph 4.4.7)
Status
Do you establish and maintain a procedure (process) for emergency Indicators of Conformity Notes
preparedness and response that addresses how to: place in place place
35. Identify potential emergency situations and potential accidents that can
have (an) impact(s) on the environment and how the organization will
36. respond?
Respond to actual emergency situations and accidents and prevent or
mitigate associated environmental impacts?

37. Does your organization periodically review and, where necessary, revise the
emergency preparedness and response procedures, in particular, after the
occurrence of accidents or emergency situations?
38. Does your organization periodically test the emergency preparedness and
response procedures where practicable?
Confirm that the procedures
have been updated, as
appropriate, in response to
new information or program
reviews.
Question Category: Checking
EMS Element 12: Monitoring and measurement (ISO 14001:2004(E), Paragraph 4.5.1)
Status
Do you establish and maintain a procedure (process) for monitoring and Indicators of Conformity Notes
measurement that ensures: place in place place
39. Key characteristics of your operations (that can have a significant
environmental impact) are monitored and measured on a regular basis?
40. Information is documented to monitor performance, applicable
operational controls, and conformity with the objectives and targets of
your organization?
41. Monitoring and measurement equipment is calibrated and maintained
and all associated records are retained?
EMS Element 13: Evaluation of compliance (ISO 14001:2004(E), Paragraph 4.5.2)
Status
Action
42. Does your procedure (process) to meet the organization's commitment to
compliance ensure that you periodically evaluate compliance with
applicable environmental legal requirements and other environmental
requirements to which the organization subscribes?
EMS Element 14: Nonconformity, corrective action and preventive action (ISO 14001:2004(E), Paragraph 4.5.3)
Status
Action

43. Do you establish and maintain a procedure (process) for controlling non-
conformities and taking corrective and preventive actions?
44. Does the procedure for controlling non-conformities and taking corrective
and preventive action ensure that:
Actual non-conformity(-ies) are identified and corrected and their
environmental impact(s) are mitigated?
Actions are taken to investigate and eliminate the causes of
nonconformities so that they do not occur again?
Actions are determined to eliminate the causes of potential non-
conformities and to prevent their recurrence?
45. Are any measures taken to identify, correct, mitigate, prevent or eliminate
the nonconformity(-ies) consistent with the magnitude of the problems and
the environmental impacts encountered?
46. After corrective and preventive actions have been taken, are they
reviewed and the program adjusted accordingly by implementing and
documenting any new changes that result from the findings?
EMS Element 15: Control of Records (ISO 14001:2004(E), Paragraph 4.5.4)
Status
Action
47. Has your organization created and maintained records as necessary
that demonstrate compliance with the EMS and conformance to the
requirements of the ISO 14001 Standard, including evaluation of
compliance with environmental legal requirements and other
environmental requirements to which the organization subscribes and
the implementation of procedures and results achieved?
48. Does your procedure (process) for records management describe how the
records will be identified, stored, protected, retrieved, retained, and
disposed?
49. Are the records themselves legible, identifiable, and traceable?
EMS Element 16: Internal audit (ISO 14001:2004(E), Paragraph 4.5.5)
Status
Does your procedure (process) for an internal environmental management Indicators of Conformity Not in Partially In Notes
Action
system audit: place in place place
50. Ensure that internal environmental management system audits are
conducted at planned intervals?

Determine whether the environmental management system conforms to
planned arrangements for environmental management including the
requirements of the ISO 14001 Standard?
Determine whether the environmental management system has been
properly implemented and is maintained?
Determine whether the environmental management system provides
information on the results of audits to management?
51. Plan, establish and maintain the environmental management audit program
taking into consideration the environmental importance of the operation(s)
concerns and the results of previous audits?
52. State the responsibilities and requirements for planning and conducting
audits?
State the responsibilities and requirements for reporting results?
Define the audit criteria, scope, frequency and methods and explain how
you have determined them?
53. Ensure that the selection of auditors and the conduct of the audits
maintains the objectivity and impartiality of the audit process?
Question Category: Management Review
EMS Element 17: Management review (ISO 14001:2004(E), Paragraph 4.6)
Status
Does your procedure (process) for Management Review: place in place place
Action
54. Ensure continuing suitability, adequacy, and effectiveness of the
environmental management system through top management review of it at
planned intervals?
55. Ensure that opportunities are assessed for improvement and the need for
changes to the environmental management system including the
environmental policy and environmental objectives and targets are
assessed?
Ensure that the results of the management reviews are documented?
56. Contain input which includes the following: results of environmental

management system audits, communication from external interested
parties, the performance of the environmental management system, the
extent to which objectives and targets have been met, status of corrective
and preventive actions, follow-up actions from previous management
reviews, changing circumstances, and recommendations for improvement?

57. Ensure that the outputs from the management review include any decisions
and actions related to possible changes to the environmental policy,
objectives and other elements of the environmental management system,
consistent with the commitment to continual improvement?
Confirm that a review
process exists to update the
policy and to communicate
changes to appropriate
stakeholders.
Program Totals
Element subtotals: 0 0 0
Program Total: 0 172 points available
Total Program percentage complete: 0
Required Documents and Records Reference Materials

Element 1: Environmental Policy
- Organization's Environmental Policy - Environmental Policy
Element 2: Environmental Aspects
- List of significant aspects - Results of environmental aspects identification process
- List of all aspects - List of critical business functions
Element 3: Legal and Other Requirements
- Laws, regulatory and other code requirements
- Voluntary standard agreements
Element 4: Objectives and Targets
- Environmental objectives and targets - List of performance measures for decontaminations process
- List of programs associated with significant aspects
- Wastewater management plan
- Hazardous management plan
- Chemical management plan
- Process Safety management
- Bloodborne pathogens program
- Communications program
Element 5: Resources, roles, responsibility and authority
- Roles, responsibilities, and authorities for the environmental management system - Job descriptions for key on site staff for programs to address
significant aspects
- Budgets
- Work schedules
- Organizational charts
- Staffing assignments
Element 6: Competence, training and awareness
- Training material and sign up sheets

- Shift change meeting notes
- Training records
- Resumes of staff responsible for key programs
- Roster of fully equipped and trained emergency personnel with the
authority to perform essential functions and activities

Element 7: Communication
- The organization's decision whether to communicate their environmental aspects externally - Key presentations
- Newsletters
- Town meeting presentations
- PR releases
- Web based information
- Communications with customers, suppliers, contractors and other
external parties
- Correspondence with management
- Master call list for employees
- Internal communication procedure
- External communication procedure
- Sample script
Element 8: Documentation
- Documents and records determined by the organization to be necessary to ensure the effective planning, operation
and control of processes that relate to its significant environmental aspects
- Description of the main elements of the EMS and their interaction and reference to related documents
Element 9: Document Control
- List of key documents
- Legal documents
- Permits
Element 10: Operational Control
- Operational Control Procedures - Procedures for different media
(where the absence of documented procedures could lead to deviation from the - Contactor environmental plans
environmental policy and the objectives and targets) - Operational controls
- Sampling procedures
- Preventative maintenance plan for equipment
Element 11: Emergency preparedness and response
- Site emergency response plan
- Incident notification procedure
- Organization evacuation procedure
- Employee meeting and disbursement procedure

Element 12: Monitoring and measurement
- Records associated with calibration and maintenance of monitoring and measurement equipment - Records of monitoring and measurements
- Information to monitor performance, applicable operational controls and conformity with the organization's - Reports of progress toward meeting objectives and targets
environmental objectives and targets
- Monitoring equipment calibrations

- Accident investigation reports
- Injury and illness reports
- Permits, licenses and other approvals
Element 13: Evaluation of legal compliance
- EMS audit and regulatory compliance audit reports
Element 14: Nonconformity and preventative and corrective action
- New changes to the program resulting from findings once the corrective and preventive actions have been taken - Reports of identified nonconformance, corrective action plans and
corrective action tracking
- Reports of hazardous material spills or other environmental
incidents
Element 15: Records
- Records as necessary to demonstrate conformity to the requirements of the EMS and of the International Standard.
- Training, environmental management audit and management review
- Sampling and monitoring data
- Equipment maintenance records
- Record retention policy
- Vital legal and financial records (accounts receivable; contracting
and acquisition files; official personnel files: social security, payroll,
retirement, and insurance records; and property management and
inventory records)
- Logs and notes for emergency response exercises
Element 16:Internal environmental management system audit
- Self assessments
- Environmental management audit reports
Element 17: Management review
- Results of management reviews - Senior managers meeting minutes
- Change to environmental management system
- Results of management review

Facility Name and Type
% Complete
100
80
60
40
20
ISO 14001:2004 EMS Elements

1 Environmental Policy
2 Environmental Aspects
3 Legal and Other Requirements
4 Objectives, Targets and Programs
5 Resources, Roles, Responsibility and Authority
6 Competence, Training and Awareness
7 Communication
8 Documentation
9 Control of Documents
10 Operational Control
11 Emergency Preparedness and Response
12 Monitoring and Measurement
13 Evaluation of Compliance
14 Nonconformity, Corrective Action and Preventive Action
15 Control of Records
16 Internal Audit
17 Management Review

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EMS Gap Analysis Questionnaire

Title: Facility Name:

Phone: Facility Type:

Roles and Responsibilities:

Conducting the EMS Gap Analysis

This is a controlled document DO NOT reproduce or distribute. Draft 2008 PPI 1

Gap Analysis Background

Gap Analysis Questionnaire Description and Directions

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Not in place = 0 points Partially in place = 1 point In place = 2 points

Question Category: Environmental Policy

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Accessing applicable legal requirements related to your organization's

17. The legal and other environmental requirements, its significant

18. Does your procedure (process) address establishing and maintaining

This is a controlled document DO NOT reproduce or distribute. Draft 2008 PPI 5

Determine whether the

Confirm that the

Verify, where possible,

Verify that the facility has a

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21. Defining, documenting and communicating the roles, responsibilities

22. Top management appointing a specific management representative who,

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Verify that the roles are

Interview staff from various

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The significant environmental impacts, actual or potential, of their work

Identify a sample of facility

Verify that these staff

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27. Establishing and maintaining procedures for receiving, documenting, and

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56. Contain input which includes the following: results of environmental

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Required Documents and Records Reference Materials

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Required Documents and Records Reference Materials

Required Documents and Records Reference Materials

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ISO 14001:2004 EMS Elements

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