Declaration of intent

1.0 Administrative
data
1.1 WEEE treated at the site and confirmation...
1.2 Description of treatment.
1.3 Annual expected throughput ( all origins)
1.4 Permits & licences of the treatment activity
1.5 Management systems

Please do not use „copy-paste“ while completing the form! Thank you.

Please make sure that the VAT code you provide is correct.

Administrative data

Note: The WEEELABEX documents relevant to each version of the “WEEELABEX Certification scheme – Operators” are available at the website: https://www.cai.cz/OA/pdf/P763_2020_EN.pdf

The conformity verification process has been initiated by:

Treatment Operator:

Member System

Member System email

Are you applying first time ?*

VAT number *

Treatment operator*

Date of Declaration of Intent*

Registred address*

Street

City

Postal Code

Country

Location to be audited*

Estimated M² of the Facility*

Total Facility area:

WEEE treatment & storage area

Prefered period for audit*

From

Participants to be involved in the Audit Process

"Treatment operator representatives: Please provide the name and the job title (same line) for the Company Manager; the Production / Operations Manager; the Plant / Site Manager and the QEHS / Administration Manager who will represent your Organisation during the audit)"

First name

Last name

Job title

Telefon/mobile

Street

City

Postal code

Country

Name

Telephone

Address

Contact details of facility representative for the audit process (email and phone number / mobile number)

First name*

Last name*

Job title*

Telefon/mobile *

Email*

Street

City

Postal code

Country

WEEE treated at the site and confirmation of those WEEE Treatment Process streams to be included in the conformity verification process

Treatment Process streams (refer to the document B02 Eligibility of Treatment Operators)

Treated/Not treated at the site

Exclusions /Exceptions ( e.g. particular equipment within the categories mentioned that are not treated at this facility)

"Shifts / number of workers(#/#)"

To be included in WX Audit Process?(yes / no)

LHA: Large appliances

CFA: Temperature exchange
equipment

Mix_SHA: Mixed equipment

CRT: CRT display appliances

FPD: Flat panel display equipment

LAMP: Gas discharge lamps

PV: Photovoltaic panels

Other

Proposed WEEELABEX Lead-Auditor *

To be approved by WEEELABEX Office

Proposed WEEELABEX Specialist CFA

To be approved by WEEELABEX Office

Proposed WEEELABEX Specialist - LAMP

To be approved by WEEELABEX Office

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Description of treatment and/or preparation for re-use

WEEE streams
– see the document B 02TR Eligibility of Treatment and Preparation for Re-use Operators

Operator Type
– see the document B 02TR Eligibility of Treatment and Preparation for Re-use Operator

Provide the details of the treatment activity

LHA: Large appliances

Type 1

Type 2

Type 3

Re-use

CFA: Temperature exchange
equipment

Type 1

Type 2

Type 3

Re-use

Mix_SHA: Mixed equipment

Type 1

Type 2

Type 3

Re-use

CRT: CRT display appliances

Type 1

Type 2

Type 3

Re-use

FPD: Flat panel display equipment

Type 1

Type 2

Type 3

Re-use

LAMP: Gas discharge lamps

Type 1

Type 2

Type 3

Re-use

PV: Photovoltaic panels

Type 1

Type 2

Type 3

Re-use

Other

Type 1

Type 2

Type 3

Re-use

Specify other

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Type 1 (Manual treatment)

Type 2 (Mechanical treatment or specific manual treatment)

Type 3 (Advanced mechanical treatment of fractions or components)

Re-use (Preparation for re-use process - checking, cleaning, or repairing recovery operations, by which products or components of products that have become waste are prepared so that they can be re-used without any other pre-processing)

Note: Definitions and descriptions of the WEEE streams and the Operator Type are defined in the document B 02TR Eligibility of Treatment and Preparation for Re-use Operators

Annual expected throughput ( all origins)

LHA:Large appliances

CFA:Temperature Exchange equipment

Mix_SHA:Mixed appliances

CRT:Display units (televisions and monitors containing cathode ray tubes)

FPD:Display units (televisions and monitors cold cathode fluorescent lamps)

LAMP:Gas dischange lamps (Category 5)

PV:Photovoltaic panels

Others

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Permits & licences of the treatment activity

Date of issue

Licencing authority

Reference Number

Type of permit

Additional details

BACK

Management systems

Management system

Quality

Environmental

Health & Safety

Others

Additional details

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Diagram of the process flow (s) to be audited

Please return a diagram of the treatment process flow with this document (attach a separate chart for each process)

Number of process stream charts attached:*

Delete attachment

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The accepted formats of attachmetns are .jpg, .jpeg, .png, .gif, .pdf, .doc, .docx, .txt, .xml, .ppt, .pptx, .pps, .ppsx, .odt, .ods, .odp, .xls, .xlsx, .zip, .rar

Declaration

By signing this form, we (the Operator) declare that the facility can attain the required recycling and recovery quota during normal business conditions according to EN 50625-1, and the required depollution performance according to EN 50625 series standards and related technical specifications.*

Have the following activities been completed?

(a) Batch (according to Annex D of the EN 50625-1) data for the treated process streams to be assessed

if Yes to (a) above:

Date of batch test and stream (fill in one row per batch):

WEEELABEX Auditor who validated the batch (name):

if No to (a) above, the Treatment Operator commits to plan the organisation of the batch tests for the appropriate treatment process streams with the WEEELABEX Lead Auditor.

(b) The depollution monitoring (according to Annex EN 50625 series standards and related technical specifications) is performed.

(c) The operator declares, that all fractions and WEEE entering and leaving the facility are documented and forwarded to operators who are in compliance with the objectives of the EN 50625-1.*

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By signing this form, we (the Operator) declare that data in the submitted Declaration of Intent is correct and true.(YES)

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