Section 1 General Information s1

Section 1 General Information

Section 2 Contact Information

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

*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

1)  Be sure to provide correct units for values.

2)  Detection limit – mark value with *.

3)  Not present – mark with NP for those metals that are not intentionally added or not expected to be present.

4)  Please provide data on hand. No new testing is required at this time.

Section 5 General Hazard and Compliance Information:

Please provide the ratings for the following categories according to the HMIS Hazard Rating system:

Recommended Personal Protective Equipment:

Section 6 Toxicological Data (as available)

Is the product tested on animals? ☐Yes ☐No

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

* 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

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.

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.

Section 9 Product Origin and Allergens

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

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.

Please explain “yes” answers:

Section 11 Food Contact Compliance (If product is NOT food contact compliant, put Not Applicable in component section below.)

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)

1)  US (FDA)

2)  EU No. 10/2011 (PIM)

3)  China (GB9685:2008)

4)  Japan (JHOSPA)

5)  South America (MERCOSUR)

Rev #: 4 Rev. Date: February 21, 2013 Page 5 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

Rev #: 4 Rev. Date: February 21, 2013 Page 5 of 11