Accept date:
Part one:Notifier Information
1.1 information of notifier (attachment number for copies of CorporateCertificate and Business License of domestic notifier: ) □post
Full Name of the Notifier:
Address / domestic / Registered address for industry and commerce: province(district, city)
city (district, canton) district
Postal code:
Actual address:
oversea
contact person: ,Tel: ,Mobile phone: ,E-mail:
Website:
Not for oversea notifier / Industry type, category: main category: second class: third class: ,
Industry code:□□□□□
Nature: □state-owned business, □private enterprise, □research institution, □others
Legal representative:
Number of employee: ,number of personnel in safety and environmental management: ,
floor area(square meter):
Membership group(or unit in charge):
1.2 Information of local representative (attachment number for copies of commission contract or treaty, legal person certificate and business license: ) □post
Full Local Representative Name:
Legal representative: / Legal representative:
contact person: ,E-mail: ,Tel: Mobile phone
Address: province(district, city) city (district, canton) district postal code
1.3 Whether you agree laternotifier to obtain your information or not? □Yes, □No
1.4 Statement
We declare that:
(1)I have known the requirements of “Environmental management on new chemical substances” and obey the relative rules.
(2) The offered information is reliable from legal source. It does not violate the rights and interests of others. If it is not the truth, I will assume all legal liability.
(3) The submitted electronic documents are completely identical in content to the hard copies.
(4)We agree to engage in manufacture of importing within the approved limits in accordance with the requirements of the Registration Certificate for the Environmental Management of New Chemical Substances.
(5) Information about hazardous properties and environmental risk for new chemical substances has been submitted.
(company stamp of notifier) (company stamp of local representative)
Legal representative Legal representative
of notifier(signature)： of local representative(signature)：
Date: Date:
Part twoBasic Information of GeneralNotification
2.1Circumstances for General Notification
□General Notification；
□Joint Notification：total______notifiers
□Serial Notification：total______chemical substances (attachment number for copies of serial notification statement documents：______)
□Repeated Notification：formerregistered number______； (attachment number for copies of the authorizationdocuments：______)
□Re-Notification for Changing Quantity Grade：formerregistered number______；
□Re-Notification for Change Use：formerregistered number______，□list in □ or don’t list in Inventory of Existing Chemical substances in China.
2.2 Quantity Grade of General Notification
□ 1≤Gradel＜10ton, □ 10≤Grade 2＜100ton, □ 100≤Grade 3＜100ton □Grade 4≥1000ton
□Manufacture, notified quantity (tonnes/year): ,anticipated place of manufacture: province(district, city) city/county
□Importing, notified quantity (tonnes/year): ,anticipated place of importing: province(district, city) city/county, port name:
2.3 Information offered by third-party(□confidentiality) □No, □Yes (attachment number of list for information offered by third-party: )
Name of third-party: , contact person:
Tel: ,Mobile phone ,E-mail:
2.4 Information of domestic processors and users(□confidentiality)
Name:
contact person: Tel: E-mail:
Address: province(district, city) city district post code:
Website:
2.5 Other information;
Part three: IdentificationofNotified substance
3.1 Name of Notifiedsubstance □ without novelty retrieval, □novelty retrieval (receipt number: )
Chemical name
(□confidentiality ) / Chinese:
English(□IUPAC, □CAS):
category: □molecular structure is unique and certain □without unique and certain molecular structure, □polymer (attachment number of polymer information )
Class name / Chinese:
English:
Other names:
3.2 Structural information
Molecular formula(□confidentiality): / Molecular weight: / CAS number(□confidentiality):
Structural formula (□confidentiality):
3.3 Impurities (□confidentiality) □without impurity,□species of impurity
CAS number / Name of impurity / Maximum content (%)
3.4 spectroscopic Data(You can chose more than one)(□confidentiality) (attachment number of spectrogram: )
□ultraviolet,□infrared, □Nuclear Magnetic Resonance, □Mass Spectrometric, □HPLC, □GC, □others
3.5 Inclusion status in other inventoried □No；□Yes (total:(amount)______)
Country or Region / Inventory Name / Inventory Registry Number / Management Requirement / Notes
3.6 The detection method in environmental medium
Environmental medium(You can chose more than one): □water, □air, □soil, □other
Part four Exposure Status of the Notified Substance
4.1 Commodity information of notifiedsubstance
Existence form(□confidentiality): □pure material □preparation, concentration of the notifiedsubstance ,medium:
□commodity(weight percent of notifiedsubstance)
Name of the marked commodity of the notified substance：
Anticipated application field: (You can chose more than one): □industry, □agriculture, □handicraft industry, □daily necessities, □scientific research,□others
Possible final whereabouts of the notified substance;(You can chose more than one):□water body, □air, □soil,□recycling,□disposal ,□others
4.2 Packaging instruction:
4.3 Summary of discharge and exposure
Exposure concentration estimate for the work environment from the use or manufacture of the notified substance: / Estimated number of person exposed in the operation: / Contact time (h/d):
Possible pathway of exposure: □inhalation exposure ,□Percutaneous exposure,□others
Exposure concentration estimate for the notified substance in the environment: / Estimated number of persons exposed in the public:
Mode of environmental exposure: □continuous/frequent, □occasional/accidental, □others
Environmental disposal medium (You can chose more than one): □water, □air, □soil, □sediment, □others
4.4 Uses information of notifiedsubstance(□confidentiality)
Major uses of the notified substance: / Potential uses of the notified substance:
Functions of the notified substance: / Expected effects of the notified substance:
Technical procedures during using notified substance / Waste generation and composition during using notified substance:
Industrial category of notified substance usage:
category / Main category / Second class / Third class / Industry code
□ □□□□
The operate methods of the notified substance：□closed system,□semi-enclosed system,□open system,□others
Part five Inherent Characteristic of NotifiedSubstance
5.1 Character of NotifiedSubstance
5.1.1State in normal temperature and pressure: □solid, □liquid, □gas, □others
5.1.2Character description:
Item / Result / Attachment number of test reports / Test / Test substance / Estimation / Literature / Confidentiality
5.2 physicochemical property
5.2.1melting point/freezing point (℃) / □ / □Pure Substance□Product / □ / □ / □
5.2.2boiling point(℃) / □ / □Pure Substance □Product / □ / □ / □
5.2.3density(kg/m3) / □ / □Pure Substance □Product / □ / □ / □
5.2.4vapor pressure(kPa) / □ / □Pure Substance □Product / □ / □ / □
5.2.5surface tension (N/m) / □ / □Pure Substance □Product / □ / □ / □
5.2.6autogenous ignition temperature (℃) / □ / □Pure Substance □Product / □ / □ / □
5.2.7flashing point(℃) / □ / □Pure Substance □Product / □ / □ / □
5.2.8oxidability / □ / □Pure Substance □Product / □ / □ / □
5.2.9flammability / □ / □Pure Substance □Product / □ / □ / □
5.2.10explosibility / □ / □Pure Substance □Product / □ / □ / □
5.2.11partitioncoefficient(n-octanol/water)(log Pow): / □ / □Pure Substance □Product / □ / □ / □
5.2.12water solubility (g/L) / □ / □Pure Substance □Product / □ / □ / □
5.2.13fat solubility (g/1000g solvent) / □ / □Pure Substance □Product / □ / □ / □
5.2.14 particle size distribution (μm) / □ / □Pure Substance □Product / □ / □ / □
5.2.15 pH value / □ / □Pure Substance □Product / □ / □ / □
5.2.16others / □ / □Pure Substance □Product / □ / □ / □
5.3 Toxicology
5.3.1acute oral toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.2acute dermal toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.3acute inhalation toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.4dermal irritation / □ / □Pure Substance □Product / □ / □ / □
5.3.5eye irritation / □ / □Pure Substance □Product / □ / □ / □
5.3.6skin sensitization / □ / □Pure Substance □Product / □ / □ / □
5.3.7repeated dose 28-day toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.8bacterial reverse mutation test / □ / □Pure Substance □Product / □ / □ / □
5.3.9in vitro chromosome aberration test / □ / □Pure Substance □Product / □ / □ / □
5.3.10in vitro mammalian cell gene mutation test / □ / □Pure Substance □Product / □ / □ / □
5.3.11bone marrow chromosome aberration in rodent / □ / □Pure Substance □Product / □ / □ / □
5.3.12micronucleus test / □ / □Pure Substance □Product / □ / □ / □
5.3.13repeated dose 90-day toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.14reproduction/developmental toxicity screening test / □ / □Pure Substance □Product / □ / □ / □
5.3.15two-generation reproduction toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.16teratogenicity / □ / □Pure Substance □Product / □ / □ / □
5.3.17toxicokinetics / □ / □Pure Substance □Product / □ / □ / □
5.3.18chronic toxicity / □ / □Pure Substance □Product / □ / □ / □
5.3.19carcinogenicity / □ / □Pure Substance □Product / □ / □ / □
5.3.20others / □ / □Pure Substance □Product / □ / □ / □
5.4 Ecotoxicology
5.4.1alga growth inhibition toxicity / □ / □Pure Substance □Product / □ / □ / □
5.4.2daphnia acute toxicity / □ / □Pure Substance □Product / □ / □ / □
5.4.3fish acute toxicity / □ / □Pure Substance □Product / □ / □ / □
5.4.4activated sludge respiration inhibition toxicity / □ / □Pure Substance □Product / □ / □ / □
5.4.5adsorption/desorption / □ / □Pure Substance □Product / □ / □ / □
5.4.6ready biodegradability / □ / □Pure Substance □Product / □ / □ / □
5.4.7inherent biodegradability / □ / □Pure Substance □Product / □ / □ / □
5.4.8hydrolysis as a function of pH / □ / □Pure Substance □Product / □ / □ / □
5.4.9earthworm acute toxicity / □ / □Pure Substance □Product / □ / □ / □
5.4.10fish prolonged toxicity test: 14-day study / □ / □Pure Substance □Product / □ / □ / □
5.4.11daphnia magna reproduction test / □ / □Pure Substance □Product / □ / □ / □
5.4.12bioaccumulation / □ / □Pure Substance □Product / □ / □ / □
5.4.13fish chronic toxicity test / □ / □Pure Substance □Product / □ / □ / □
5.4.14seed germination/root elongation toxicity test / □ / □Pure Substance □Product / □ / □ / □
5.4.15others / □ / □Pure Substance □Product / □ / □ / □
Part six Environment and Safety Information
ofNotifiedSubstance
6.1 Notes in Operations:
6.2Notes in Storage
6.3 Notes in Transportation:
6.4 Personnel Protection Information:
6.5 Emergency measure for accident:
6.6 Waste disposal measures:
6.7 Measures of Collection and Disposal of Leakage：
6.8Opinions on Environment Recovery Measures after Accident：
6.9 Pollution Prevention Methods：
Part seven Other Information of Notified Substance
7.1 Measures for Control of Environmental Risks:： / Statement of appropriateness of risk management measures:
7.2 Measures for Control of Health Risks: / Statement of appropriateness of risk management measures:
7.3 3 Environmental Friendliness Statement:
7.4 Description of Results of Hazard Classification:
(Attachment No. of Results and Basis of Hazard Classification： )
7.5 Label(attachment number of label: )
7.6 Material Safety Data Sheet (MSDS) (attachment number of MSDS: )
7.7 Attachment of thisnotification: this form contains attachments in total (attachment number of attached list: )
Ministry of Environmental Protection of the People’s Republic of China, 2010
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