PRODUCT REGISTERDECLARATION FORM FOR

Norwegian Environment AgencyCHEMICAL PRODUCTS

Postboks 6257 Etterstad , 0603 Oslo

Telephone: + 47 73 58 05 00

Telefax: + 47 23 24 17 93

Shaded boxes to be completed by Product Register

Declaration no

1. Trade name for substance or mixture as shown on the label: / 2. Classification
Enter theclassificationeitheraccording tothe Norwegian Regulationsrelating to classification, labellingetc. of dangerous chemicals or theRegulation (EC) No. 1279/2008 (CLP)
Symbol letter, R-phrases according toChemical labelling regulations:
No. of variants (for simplified declarations only): ...... / Signal words, code forhazard pictogramsand codesforhazard statementsaccording toCLP:
Mark if product is solely raw material: / Labelled on the basis of tests? / Yes / No
Box 1: Concerning simplified declarationsee guidelines

3. Company responsible forfilling out the declaration form:Enterprise no. (Norwegian company only)

______

Telephone

Address______

E-mail

______

Box 3:Another company may fill out the declaration form, but the final legal responsibility rests with the first company in Norway to import the chemical product. They will be legally responsible under the Norwegian law for the completeness and accuracy of the information provided.

4. Quantities: / Tonnes/year
Figures for year: / Produced
Imported
Renamed
Exported
Box 4: Quantities in tonnes/year.
5. Manufacturer:
Company name: / Telephone:
Address: / E-mail:

Box 5: Give the name of the actual manufacturer of the chemical.

6. Company name on label:
Name: / Country:
Address: / Telephone:

Box 6: Give the name and address of the company in the EEA named on the label.

TB-0800EPage1 of 4

7. List of customers/Norwegian distributors:
Name / AddressEnterprise no / Telephone/E-mail

Box 7: If the company responsible for filling out the declaration form is not Norwegian, please give the name of the Norwegian customer (first company in the chain of distribution) here. Append a separate list if there is too little space.The Enterprise number should be available through your customer/distributor.

8. Branches of industry where the product is used (one line per branch): / Branch code / %-distribution
Are the chemicals also used for non-occupational purposes? If «YES», give the percentage of non-occupational purposes / YES: / NO: / PR1
Sum 100%
Give a description of the branches where the product is used:
Box 8: List the branches of industry that you consider to be the most important (use codes or key words) and % for each. Unspecified branches should be < 20% of the total. Examples of branches of industry: 26.5, “Manufacture of cement” and 11.1, “Extraction of crude petroleum and natural gas”.
9. Product type (one line per product type): / Code / %-distribution
Sum100 %
Description of the product type:
Box 9: List the product types that you consider to be the most important (use codes or key words) and % for each. Unspecified types should be < 20% of the total. Examples of product types: “Cleaning product for floors” and H1520, “Glue hardener”.

TB-0800EPage1 of 4

10. Constituents of the chemical product:
No. / Identification number / Unambiguous chemical name/Raw material name /

Function

(code) / Classification according to the Norwegian regulation relating to classification, labelling etc. of dangerous chemicals:Symbol letter, R-phrases and Notes / Classificationaccording to CLP:
Hazard Class, Hazard Category,
Hazard
statement
Code(s) and Notes / Given on label?
(yes/no) / Weight-%
CAS-no.
/P-no.| / EC-no.
Are all the constituents given? / Yes / No / Sum weight %
(=100)
Box 10: List all constituents with identity numbers (CAS/EC no.), unambiguous chemical names, functions in the chemical, classification and exact % by weight. Raw materials may be listed with declaration numbers if available. Examples of functions are corrosion inhibitor, plasticizer, siccative, etc. Give any further information on health and environmental risks in box 12. Constituents must be numbered (first column), as the numbers will be used for reference in any subsequent correspondence. Append a separate list if there is too little space.

TB-0800EPage1 of 4

11. Physical data:
Form/consistence: Tick here:
Fast (briquettes/rods) / Partition coefficient (n-octanol/water):
Powder / Bio concentration factor (BCF):
Pasta / pH (as sold):
Liquid / Specific weight kg/m3:
Gas / Tick if the chemical contains nanomaterials:
Aerosol / Nanomaterials are manufactured substances with one or more dimensions at nanoscale (1- 100nm) or an internal or surface structure at the nanoscale, manufactured to have specific composition to utilize specific properties.
Flash point oC:
(Mandatory for flammable liquids) / Method used
(CC/OC)
12. Other relevant information:
13. Confidentiality and signature:
In principle all information given to government authorities shall be available to the public. If some information must be treated as confidential, please indicate the information you want to be treated as confidential. Information available from other sources (e.g. safety data sheet or label) will normally not be confidential.Information that you want to keep confidential has to be specified and argued for below in brief. A more thorough argumentation must be available upon request from the Norwegian authorities. All information that is not specified as confidential will be treated as public information.
Does this form have information that you want to keep confidential? Yes No
Protection of information is in accordance with the Norwegian Product Control Act.
How to understand the table below:
-Protection of trade name: The chemicalshall not be linked to your company in any public information.
-Protection of quantities: Quantities shall not be public information except as part of anonymous statistics.
-Protection of manufacturer: Manufacturer is not to be identified to the public.
-Protection of Norwegian distributors: Distributors are not to be identified to the public.
-Protection of the composition: No part of the constituents is to be public information. If information about constituents stated on a safety data sheet should be treated as confidential, this must be stated explicitly.
-If the information that the chemical contains nanomaterial should be treated as confidential, this must bestated here.
Subject / Trade secret (tick box) / Reason why the information shall be kept confidential
Trade name
Quantities
Manufacturer
Norwegian distributors
Constituents of the product
Nanomaterials
I hereby confirm that the information given aboveis correct and will be updated regularly. I understand that all documents of relevance to the completion of the declaration form shall be available in the company.The authorities may require such documentation to be submitted on request.
For the company
Date: / signature:

TB-0800EPage1 of 4