Chemical product declaration form

Technical Expertise and
Consulting /
Chemical Risks
_________________________
65 Boulevard Richard Lenoir
75011 PARIS
Tel: +33(0)1 40 44 30 83
Fax: +33(0)1 40 44 30 54
SIRET: 775 671 456 00082
APE: 7219Z
www.inrs.fr
CHEMICAL PRODUCT DECLARATION FORM
Confidentiality of data entered on this form by the registrant is guaranteed under the provisions of
Articles 226-13 of the French Penal Code, R. 4411-46 of the French Labour Code and L. 1343-3 of the
French Public Health Code.
This declaration form must be accompanied by:
the material safety data sheet if it has been established,
the product labels for all declared commercial designations (for your company and your distributors)
a company headed letter, stating the commercial designation of all products declared in addition to any other
relevant information.
If you are declaring a product for your distributor, you should also attach to your declaration a certificate from that
distributor authorising you to make the declaration on its behalf.
This form has several sections:
I)
REGISTRANT
This section shall contain a maximum of information on the declaring company and the person making the
declaration (who may be different to the person signing the form).
II)
CONTEXT
This section consolidates general information on the declaration background, specifically the type of declared product.
III) PRODUCT IDENTIFICATION
This section contains all the existing commercial designations (as they appear on labels) and/or known internal
codes for the product.
Should the registrant not be responsible for placing certain designations on the market, he should detail the relevant
product name(s) and the person(s) responsible for placing this (these) designation(s) on the market. In this case, a
stockist or distribution company headed letter detailing purchase from the supplier and re-sale of the declared
product shall be forwarded to INRS and enclosed with this declaration form.
IV) STATUTORY LIST
This section only concerns biocidal products and details their different types (PT). Selection is compulsory.
V) PRODUCT USAGE
This section features two sub-sections: Usage(s) and Fields of activities for the declared product. At least one item
must be detailed in each sub-section.
VI) MARKETING
This section refers to the quantity of product placed on the market and packaging. Only products of different
composition according to packaging shall be declared on separate forms.
VII) PHYSICAL CHARACTERISTICS
This section must include all available information on the product’s organoleptic and physico-chemical characteristics.
VIII) PRODUCT COMPOSITION
The declared composition must be exhaustive quantitatively and qualitatively and shall not include value ranges.
If, and only if a constituent cannot be precisely identified, state the commercial designation together with the contact
information of its supplier. You must enclose the relevant material safety data sheet.
If the entire composition is not known (resale product), state the manufacturer’s name and the commercial
designation under which the product is sold and enclose the relevant material safety data sheet.
For biocidal products, you must state the active substance(s): AS
IX) LABELLING
Quote the product labelling data (according to Regulation (EC) 1272/2008 – CLP or to Directive 1999/45/EC).
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CHEMICAL PRODUCT DECLARATION
Highlight confidential information with an asterisk (without prejudice to Articles R. 4411-42 and 43 of
the French Labour Code, R. 1341-2 to 10 and R. 1342-13 to 19 of the French Public Health Code and
R. 522-39 and 43 of the French Environmental Code)
I) REGISTRANT
1) Company:
- Company Name:
- SIRET code:
- VAT code:
- Address:
- Postal code:
- City/Town:
- Country:
- Telephone:
- Fax:
- E-mail:
- Website:
2) Person:
- Title:
Ms.
Mr.
- Surname, First Name:
- Address:
- Postal code:
- City/Town:
- Country:
- Telephone:
- Fax:
- E-mail:
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II) CONTEXT
1) Type of declaration:
Biocide declaration
Plant protection declaration
Other declaration
2) Is this an answer to a declaration request? (further to a request mail):
Yes
No
Request number (appears on the mail):
3) Usage:
Industrial
General Public
Combined
III) PRODUCT IDENTIFICATION
1) Commercial designation of your product (as mentioned on label):
1
- Main commercial designation :
- Brand / Line:
- Internal denomination / Product code:
1
- Synonym(s) for your company :
1
2) Existing French synonyms for other companies/distributors :
Commercial designation
Brand / Line
Distributor / Importer
2
1: enclose the relevant label
2: distributor is the company which appears on the label. Enclose relevant certificate from this distributor.
3) Registrant’s status:
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Manufacturer
Importer
Distributor
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IV) STATUTORY LIST (Biocidal products only)
PRODUCT TYPE(S)
PT
PT
PRODUCT TYPE(S)
1
Human hygiene
12
Slimicides
2
Disinfectants and algaecides not intended for
direct application to humans or animals
13
Working or cutting fluid preservatives
14
Rodenticides
3
Veterinary hygiene
15
Avicides
4
Food and feed area
5
Drinking water
16
Molluscicides, vermicides and products to
control other invertebrates
6
Preservatives for products during storage
17
Piscicides
7
Film preservatives
18
8
Wood preservatives
Insecticides, acaricides and products to control
other arthropods
Fibres, leather, rubber and polymerised
materials preservatives
19
Repellents and attractants
9
20
Control of other vertebrates
10
Construction material preservatives
21
Antifouling products
11
Preservatives for liquids-cooling and
processing systems
22
Embalming and taxidermist fluids
V) PRODUCT USAGE
1) Usage(s) (what is the product used for?):
2) Fields of activities:
Aeronautical industry
Agriculture
Agrochemical industry
Basic chemical industry
Breeding
Building and civil engineering industry
Car industry
Electrical and electronic industry
Food industries
Glass, porcelain, earthenware and ceramic industry
Glue and adhesive industry
Leather and shoe industry
Local Authority
Maritime industry
Metallurgy and foundry work
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Mineral oil and fuel industry
Paint and varnish industry
Paper and cardboard industry
Petroleum industry
Pharmaceutical industry
Photographic industry
Publishing, printing and copying
Rubber, plastic and polymer industry
Soap, perfume and cleaning product industry
Textile and dyeing industry
Wood industry
Other chemical industries
Other manufacturing industries
Domestic – General public
Unknown
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VI) MARKETING
3
(Units to be used: kg, t, g, l, cl, ml, m )
1) Information about launch on the market:
- Quantities placed on market annually:
(Example for 100 kg sold in 2012: year: 2012; quantity: 100 kg,)
Year:
Quantity:
Year:
Quantity:
- Date of launch on French market (DD/MM/YYYY):
/
/
- Date of launch on the market for this formulation (in case of update):
/
/
- Possible authorisation already given (marketing authorization):
Date:
Authority responsible:
Ministry of
Agriculture
Ministry of
Health
Ministry of the
Environment
2) Types of packaging:
(For a can of 250 mL:
Can, Capacity: 250 mL)
Can
Bottle
Packet
Cardboard
Container
Bucket
Box
Other:
Can
Bottle
Packet
Cardboard
Container
Bucket
Box
Other:
Drum
Drum
Capacity:
Capacity:
VII) PHYSICAL CHARACTERISTICS
1) Physical status when stored:
Liquid
Liquid (water soluble dose)
Viscous/Oily liquid
Gel
Paste/Cream
Ointment
Wipe
Solid
Powder
Granule
Tablet/Pastille
Gas/Vapour
Aerosol
Unknown
Paste/Cream
Ointment
Wipe
Solid
Powder
Granule
Tablet/Pastille
Gas/Vapour
Aerosol
Unknown
2) Physical status when used:
Liquid
Liquid (water soluble dose)
Viscous/Oily liquid
Gel
3) Smell:
4) Colour:
5) pH:
6) Flash point:
7) Viscosity:
applicable:
No
applicable:
Unit:
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Yes
No
to
Yes
If yes, pure product pH:
or diluted solution:
, concentration
If yes, flash point:
°C
°C
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VIII) PRODUCT COMPOSITION
1) Composition is known
- Give the exact chemical name of all constituents with their CAS number and exact percentage content.
- Composition must be exhaustive (= 100%)
- If, and only if a constituent cannot be precisely identified, state the commercial designation together with the
contact details of its supplier. You must enclose the relevant material safety data sheet.
- For biocidal products, you must state the active substance(s): AS
Exact chemical name of constituents
CAS number
Exact %
AS
Remark: particular case of polymers formed in-situ without CAS number or EC number: state its entire
chemical name, its type (acrylic, polyester, etc.) and monomers used with their respective CAS numbers.
2) Entire composition is not known (resale product)
(Enclose supplier’s material safety data sheet and in case of biocidal products, indicate the active substance(s) in the table
above):
- Supplier’s name and address:
- Supplier’s commercial designation for the product:
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IX) LABELLING
Is product labelled according to applicable regulations (product classified as hazardous)?
No
Yes
If yes:
1) Classification according to Regulation (EC) No 1272/2008 (CLP):
GHS pictogram(s):
Signal word:
Warning
Danger
None
Hazard statement(s) (H):
Supplemental hazard statement(s) (EUH):
Precautionary statement(s) (P):
2) Classification according to Directive 1999/45/EC:
Danger symbol(s):
Risk phrase(s) (R):
Safety advice (S):
X) SIGNATORY
In
on
Surname and first name of signatory:
Signature:
Please enclose MSDS and label of the product
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