F393(GL)v01enECOCERT Greenlife 10/02/2011

Questionnaire for cleaning products checking according to COSMOS standard and Ecocert Greenlife standards for Ecoproducts (cosmetic, detergent, paints and home perfume)

This questionnaire must be completed and signed by the manufacturer of the cleaning product; information given is under his own responsibility.

A TDS and a MSDS must be joined to this questionnaire for its studyi.

If data are confidential, the questionnaire can be sent directly to the Ecocert Greenlife certification officer who is dealing with your client. Propriatary information will be guaranted.

COMMERCIAL NAME:

I –General information about your company and your product:

  1. Cleaning product manufacturer:

Company name:
Address:
Country:
Telephone: / Email:
Fax:
  1. Supplier/Distributor, ifdifferent:

Company name:
Address:
Country:
Telephone: / Email:
Fax:
  1. Function:

II – Product labellisation:

Do your product has a label?Yes No

If yes, which one?:

III - Composition of your product:

  1. Composition:

What is the composition of your product (according to the regulationEC N°648/2004)?:

  1. Prohibited ingredients:

Do your product contain:

- formol?Yes No

- Products based on genetically modified microorganisms (enzymes, bacteries)?

Yes No

- Products based on chlorine or chlorine derived?Yes No

- Ammonium-based products?Yes No

- EDTA? Yes No

- Products based on phosphates? Yes No

- Products based on phosphonates?Yes No

IfYes, precisetheirfunction:
  1. Surfactants:

Do your product contain surfactants?Yes No

If Yes, which ones? (chemical name):

Have they a plant origin?Yes No

Is their aquatic toxicity low (EC50 or IC50 or LC50 > 10 mg/l or an equivalent test)?

Yes No

Is their primary biodegradabilityfast and complete ultime (OECD 301>70% in28 days)?

(according to the regulation EC N°648/2004)Yes No

Do your product contain ethoxylated surfactant?Yes No

If Yes, which ones? (chemical name):
How many ethoxylate contain each surfactant?
What is the percentage of ethoxylated surfactants on the total of surfactants of your formula?
  1. Disinfectant ingredients:

Do your product contain disinfectant ingredients? (as autorised in the Biocide regulation EC N°98/8)? Yes No

ifYes, which ones?:

If you use ethanol as a disinfectant ingredient or for an other function, precise its origin: Plant origin Synthetic origin

  1. Environnement:

Do the ingredients of your product present environnemental risk sentences?

Yes No

IV –Additional information for the COSMOS standard only:

Could you declare all the ingredients of your product in the following board:

Ingredient (chemical name or INCI) / Origin (vegetal, synthetic…) / Manufacturing process

I undersigned, , representing the company, , declare that the information given in this questionnaire is correct.

Issued in , on the .

Obligatory signature (preceded by the mention «read and approved»)

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