Section 1 General Information

Section 1 General Information

Product Name:
Supplier Product No.:
Country of Origin: / Grade: (delete the irrelevant) technical, cosmetic, food, pharma, NA
Please provide Safety Data Sheet for United States and European Union.
Supplier Company Information / Manufacturer Company Information
Name / Name
Address / Address
Phone / Phone
Website / Website
ISO Certifications: / List all & provide certificates / ISO Certifications: / List all & provide certificates
Trade Associations: / List all (global) to which you hold a membership / Trade Associations: / List all (global) to which you hold a membership
Participate in Responsible Care® or similar program? / Yes/ No / Participate in Responsible Care® or similar program? / Yes/ No

Section 2 Contact Information

Commercial Contact / Technical Contact / REACH Contact
Name
Address
Phone
Email
Purchasing Contact / Regulatory Contact
Name
Address
Phone
Email

The below signature certifies that all the information supplied in this form is current, complete, and accurate. The supplier understands that Milliken & Company is relying on Supplier’s certification to ensure Milliken & Company’s compliance with applicable global legal requirements and regulations.

Name:

Phone:

Email:

Signature:

Date:

Section 3 Environmental Compliance

1* / 2* / 3* / 4* / 5* / 6* / 7*
A response for each section is required.
Regulated Components / CAS # / Max Wt% / CAA HAP / CAA VOC / State TAP / CWA / CERCLA RQ (lbs) / SARA 302 EHS / SARA 313
1
2
3
4
5
6
7
8
9

*see Appendix A for explanations

Answer at least one of the below questions with regards to Volatile Organic Compounds (VOCs):

1)  Total VOC’s by EPA method 24/24A (%):______

2)  Total VOC’s estimated based on product composition (%): ______

Section 4 Metals Analysis

(If the number you provide is the detection limit, please mark with *. For those metals that are not intentionally or not expected to be present, please mark with NP.)

Metal / Max Value / Metal / Max Value / Metal / Max Value
Al / Aluminum / Sb / Antimony / As / Arsenic
Ba / Barium / Be / Beryllium / Bi / Bismuth
B / Boron / Cd / Cadmium / Cr III / Chromium III
Cr VI / Chromium VI / Co / Cobalt / Cu / Copper
Fe / Iron / LI / Lithium / Hg / Mercury
Mg / Magnesium / Mn / Manganese / Ni / Nickel
Pb / Lead / Se / Selenium / Ag / Silver
Te / Tellurium / Tl / Thallium / Sn / Tin
Sn / Tin organic / Zn / Zinc

Section 5 General Hazard and Compliance Information:

/ No / Yes / Details /
Is the product considered a RCRA Hazardous Waste? / ☐ / ☐ / characteristic/waste code(s):
info
Is product hazardous under the OSHA HAZCOM standard? / ☐ / ☐
Is the product a SARA 311/312 Hazard? / ☐ / ☐ / Please delete the hazards which do not apply to this product: acute/chronic/fire/pressure/reactive
info
Is the product DOT regulated? / ☐ / ☐ / Proper shipping name:
info
Is the product compliant to CONEG? / ☐ / ☐
Is product EU Council Reg. EC No 2037/2000 compliant? / ☐ / ☐
Is the product or any components regulated by California Proposition 65 (Prop 65)? / ☐ / ☐ / Substance:
info
Is the product classified according to DSD (67/548/EEC), DPD (1999/45/EC),and CLP (1272/2008)? / ☐ / ☐ / If yes, please specify.
info
Is the product compliant to Directive 2011/65/EU on the restriction of the use of certain hazardous substances in electrical and electronic equipment (RoHS) and is the product compliant to Directive 2002/96/EC on waste electrical and electronic equipment (WEEE)? / ☐ / ☐
Is the product compliant to Directive 94/62/EC on packaging and packaging waste? / ☐ / ☐
Is the product compliant to Directive 2000/53/EC on end-of life vehicles? / ☐ / ☐
Is the product compliant to Safety of Toys EN 71 part 3 and part 9? / ☐ / ☐
Is the product compliant to the Cosmetics Directive 76/768/EC and its subsequent amendments? / ☐ / ☐
Does your product have any approvals or certifications for US or EU Pharmacopoeia? / ☐ / ☐ / Please specify Monographs
info
Is this product classified under UN-GHS regulations? / ☐ / ☐ / If yes, please specify.
Is this product classified under German Water Hazard (WGK)? / ☐ / ☐

Please provide the ratings for the following categories:

Health / Flammability / Reactivity
Flashpoint:

Recommended Personal Protective Equipment:

Section 6 Toxicological Data (as available)

Data / Species / Test Method
Ingestion LD50 (mg/Kg)
Inhalation LC50 (mg/Kg)
Respiratory Sensitizer
Eye Irritation / Damage
Dermal LD50 (mg/Kg)
Skin Corrosion / Irritation
Skin Sensitizer
Fish Tox LC50 (mg/L)
Daphnia LC50 (mg/L)
Mutagenicity
Carcinogenicity
Reproductive Toxicity
Subacute/Subchronic Toxicity
Biodegradability (aerobic & anaerobic)
Octanol Water Partition Coefficient Kow
Additional Data

Is the product tested on animals? ☐Yes ☐No

Section 7 International Chemical Substances Approvals (include impurities or by-products)

Component / CAS RN / Wt% / US - TSCA / Canada- NDSL / Canada- DSL / EU- EINECS* / EU – ELINCS* / Australia – AICS / Japan – ENCS / Korea – ECL / Philippines – PICCS / China – IECSC / New Zealand – NZIoC / Taiwan - ECN

* EC No.: ______

1)  Is this product or any component subject to regulation by US EPA such as SNUR, PAIR, etc? ☐Yes ☐No If yes, please explain.

Section 8 REACh Status

n / y / Comments
Pre-registered / ☐ / ☐
Registered / ☐ / ☐ / If yes, Reg No.: / If no, planned date:
Exempted / ☐ / ☐ / Reason:
Uses Supported / ☐ / ☐
Use Description

Substances of Very High Concern (SVHC)

reference link: Candidate List

☐ Our product defined above does not contain any of the chemicals listed in the Candidate List (last update prior to completion date of this form) of Substances of Very High Concern for Authorization stated in the REACH Regulation (1907/2006/EC), in a concentration above 0.1%.

☐ As revisions are made to the Candidate List which effect a change in the status of the subject product supplied to Milliken & Company by our company, we will communicate the change in status within 30 days.

Please complete the table below for any components that are on the List of Substances of Very High Concern for Authorization, last update prior to completion date of this form. Add lines as needed.

Name of Substance / CAS No. / EC No. / Contents %

Classification, Labeling, and Packaging (CLP)

Has the material CLP classification and labeling been notified in accordance with Article 39 of Classification, labeling, and packaging of substances of mixtures regulation 1272/2008?

☐Yes ☐No

If no, please state reason:

If yes, what is the hazard classification?

Please mark with an “X” in the appropriate box(es) below if any of the substances are classified as carcinogenic, mutagenic, or reprotoxic in accordance with 67/548/EEC and CLP Regulation No. 1272/2008 and their subsequent amendments.

Category 1 / Category 2 / Category 3
Yes

Section 9 Product Origin and Allergens

Does this product contain or is derived from any of the below?

/ Y/N / Substance / Max Amt / CAS # /
Genetically Modified Organisms
Synthetic origin?
Mineral origin? Specify
Animal Origin? Specify
Contains BSE/TSE?
Plant Origin? Specify
Allergens:
Peanuts
Soy Beans
Milk
Eggs
Fish
Crustaceans
Tree Nuts
Wheat
Cereals w/gluten
Celery
Sesame Seed
Other- specify

Is product Kosher certified? ☐Yes ☐No

Is product Halal certified? ☐Yes ☐No

Section 10 Substances of Concern

Does your product contain any of these substances of concern? Please explain any “yes” answers below the table.

/ Y/N / Max Amt / Chemical name / CAS # /
Algaecide/Biocide
Alkyl phenols (straight chain) and their ethoxylates
Aromatic amines
Aromatic hydrocarbons
Asbestos
Azo colorants/compounds
Bisphenol A
Brominated flame retardants (other than PBB/PBDE)
Butylated Hydroxytoluene (BHT)
Canadian Challenge Substances
Defoamers
Diaryl Pigments
1,4-Dioxane
Dioxins/Furans (e.g. brominated/chlorinated)
Epoxy derivatives (e.g. BADGE, BFDGE, NOGE)
Ethylene Oxide
Fluorochemicals
Formaldehyde or potential formaldehyde releasers/donors
Halogens and their compounds
(e.g. brominated/chlorinated)
Mono- and Diethylene series glycol ethers
Naphthalene
Natural Latex
Nonyl phenol and nonyl phenol ethoxylates
Organotin Compounds
(Tributyl tin or Triphenyl tin compounds)
Ortho Phenyl Phenol
Ozone Depleting Substances, Class I
Ozone Depleting Substances, Class II
Paradiclhorbenzene (PDCB)
Perfluorooctanoic Acid (PFOA)
Phthalates
Polybrominated biphenyls (PBB)
Poly brominated diphenyl ethers/oxides
(PBDE/PBDO)
Polybrominated Flame Retardants (PBFR)
Polychlorinated biphenyls (PCB)
Polychlorinated terphenyls (PCT)
Polychlorinated naphthalenes
(PCN) - (>3 Cl atoms)
Polyvinyl chloride (PVC)/ PVC Blends
Radioactive Substances
Shortchain Chlorinated paraffins
(C10-13; Cl>=50 wt%)
Sodium nitrite and/or added secondary amines, nitrosating agents or preformed nitrosamines e.g. surfactant/preservative and surfactant/nitrite combinations that may lead to the formation of nitrosamines
Surface Active Agent
Triclosan
Tris (nonylphenyl) Phosphite
Volatile Organic Compounds (VOC)

Please explain “yes” answers:

Section 11 Food Contact Compliance Click here to choose

Please supply applicable reference numbers, conditions, exemptions, restrictions and/or specifications below the table in the appropriate area. Be sure to include all substances with a Specific Migration Limit (SML).

(Add lines to table as needed)

Please put an “X” in the appropriate box if the component complies with:
Component / United States (FDA) / EU No 10/2011
(Plastics Implementing Measure, PIM) / China (GB9685:2008) / Japan (JHOSPA) / South America (MERCOSUR) / Dual Use Additive? / (EC) No. 1935/2004 / (EC) 2023/2006 (GMP) / Compliance with BfR- list paragraphs

1)  US (FDA)

2)  EU No. 10/2011 (PIM)

3)  China (GB9685:2008)

4)  Japan (JHOSPA)

5)  South America (MERCOSUR)

Rev #: 3 Rev. Date: April 24, 2012 Page 2 of 11

Appendix A

Explanation and instructions for Environmental Compliance section.

*1- CAA HAP

- Hazardous Air Pollutant, including all chemicals listed in the 1990 Clean Air Act (Note: No de minimus level for HAPs). Please put “Y” for Yes or “N” for No.

*2- CAA VOC

-VOC as defined by 40 CFR 51.100. Please put “Y” for Yes or “N” for No.

*3- State TAP

- South Carolina Standard 8 TAP. Please put SC, if this applies.

*4- CWA

- Priority Pollutants as specified by 40 CFR 401.15. Please put “Y” for Yes or “N” for No.

*5- CERCLA RQ (lbs)

- In this column, please enter the CERCLA Reportable Quantity (RQ) or Section 304 EHS RQ for the component, whichever is less. If the component does not have a Reportable Quantity under CERCLA or Section 304, please enter “None” rather than leave the column blank. CERCLA RQs can be found in 40 CFR 302.4. Section 304 RQs can be found in 40 CFR 355 Subpart D. Both can be found in the EPA’s List of Lists. (Be aware that the List of Lists is current only to 2006.)

*6- SARA 302 EHS

- SARA Extremely Hazardous Substance. Section 302. Please put “Y” for Yes or “N” for No.

*7- SARA 313

- SARA Toxic Chemical Section 313 (40 CFR 372 & amendments published in the Federal Register). Please put “Y” for Yes or “N” for No.

Change Log

Date / Rev # / Initials / Description of Change
9/2/11 / 1 / ALR / logo
3/1/12 / 2 / ALR / Added statement under SVHC for supplier pro-active communication; Added flashpoint; added link to CONEG facts sheet; Added metals for EU; Added web link for WEEE; Added ELV
4/24/12 / 3 / ALR / Added ISO certs, RC participation, Trade associations; reformatted CLP CMR

Rev #: 3 Rev. Date: April 24, 2012 Page 2 of 11