Information Sheet(Page1) by coryelJudie


									 ⅣChemical Substance Contents Information Sheet
Enter according to the entry guide
                                                                                     Request No.
                                                                                     Date of request
Information about the target company of the survey
Company name                                                                        Address
DUNS numbar                                                                         Phone
Section name                                                                        Fax
Person in charge                                                               Seal E-mail address

[Basic Information about Parts]
                             Manufactuer                Model               Data      Data of     weight
   Parts No.    Part name                                                                                     substances are
                               name                     number             version    revision   of survey

[Chemical Substance Contents Information]
    Class No. for                                                          Substance details     Content Portion where the
                              Substance groups
     substance                                                              Present/Absent         mg    substance is used
        A05        Cadmium and Cadmium Compounds                               Yes/No
        A07        Hexavalent Chromium Compounds                               Yes/No
        A09        Lead and Lead Compounds                                     Yes/No
        A10        Mercury and Mercury Compounds                               Yes/No
        A17        Tributyl Tins Oxide (TBTO)                                  Yes/No
        A18        Tributyl Tins(TBT) & Triphenyl Tins(TPT)                    Yes/No
        B02        Polybrominated Biphenyls (PBBs)                             Yes/No
Level A

        B03        Polybrominated Biphenyl ethers(PBDEs)                       Yes/No
        B05        Polychlorinated Biphenyls (PCBs)                            Yes/No
        B06        Polychloronapthalenes (C1=>3)                               Yes/No
        B09        Short Chain Chlorinated Paraffins                           Yes/No
        C01        Asbestos                                                    Yes/No
        C02        Azo Colorants                                               Yes/No
        C04        Ozone Depleting Substances                                  Yes/No
        C06        Radioactive Substances                                      Yes/No
                            Perfluorooctane Sulfonates (and their salts)
               A01          Antimony and Antimony Compounds                    Yes/No
               A02          Arsenic and Arsenic Compounds                      Yes/No
               A03          Beryllium and Belyllium Compounds                  Yes/No
               A04                                                             Yes/No
Level B

                            Bismuth and Bismuth Compounds
               A11          Nickle and Nickle Compounds                        Yes/No
               A13          Selemium and Selemium Compounds                    Yes/No
               B08          Brominated Flam Retardants                         Yes/No
               B07          Vinyl Chloride Polimer (PVC)                       Yes/No
               C05          Phthalates                                         Yes/No
 substances in
Attached Table 2
 are contained


Purpose of use
[Chemical Substance Contents Information]
Metals, alloys and metal compounds in Groups A (enter according to the metal content)
 Class No.    Typical                                        Metal    Compoun Metal       Portion where
                              Substance name        CAS
    for      substance                                     conversion     d    content    the substance
                         (in Japanese or English)   No.
 substance   class No.                                       factor    content  (mg)         is used


[Chemical Substance Contents Information]
Chemical Substances in Groups B and C (Enter the CAS number or ISO 1043-4 code if a B08 brominated
flame retardant is contained)
 Class No.    Typical                                                                     Portion where
                              Substance name         CAS No. or ISO    Compound content
    for      substance                                1043-4 code           (mg)          the substance
                         (in Japanese or English)
 substance   class No.                                                                       is used

WE028                                                      Total

a B08 brominated


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