CONFIDENTIAL APPENDIX
For all Hazardous Substance applications
Send to Environmental Protection Authority preferably by email (HSApplications@epa.govt.nz) or alternatively by post
(Private Bag 63002, Wellington 6140)
Payment must accompany application; see our fees and charges schedule for details.
Please use this form to provide confidential information for your application. This form should be
provided with the main application form.
Name of the substance to be approved
Date
www.epa.govt.nz
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Confidential Appendix For all hazardous substances applications
1. Composition details of the formulated substance
Full composition details must be supplied
Please complete one of the two sections below.
☐ Full details are provided below
For every ingredient in the formulation, each column must be completed.
CAS
number
Component name1
Function2
Concentration
(g/L or g/kg) –
Min and Max
Concentration
(%) – Min and
Max
Total weight/weight (solids) or weight/volume (liquids)
Specific gravity (liquids only)
☐ I have arranged for the owner of the formulated substance who granted the rights to handle the
approval of the formulated substance in New Zealand to provide details to the EPA using a copy of
this page
Formulator name
Contact name
Job title
Postal address
Physical address
Phone (office and /
or mobile)
1
Include purity details where relevant, e.g. 95% purity, sufficient to give 100 g/L. Trade names cannot be used on their own. If
trade-named products are used as an ingredient, provide full formulations of all trade name products used, or arrange to have
complete formulations sent directly to the EPA by the supplier.
2
The purpose of the ingredient in the formulation (e.g. solvent, binder, preservative etc); do not record as ‘inert’
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Confidential Appendix For all hazardous substances applications
2. Source of active ingredient(s)
You only need to complete this section if you are using the pesticides or veterinary medicines main application
form
Company Name:
Contact Name:
Job Title:
Actual site of manufacture (address):
Postal Address (provide only if not the same as the physical):
Phone (office and / or mobile):
Fax:
Email:
Minimum purity of the active ingredient as manufactured (g/kg):
Any impurities where the toxicology and ecotoxicology is known and of no concern and which are
present at a concentration of 10 g/kg or more, must be identified, quantified and reported. Any
impurities or residues of toxicological concern present at any level, including those present at less
than 10 g/kg (1%), must be identified, quantified and reported. Any impurities where the toxicology and
ecotoxicology is unknown and which are present, at any level, must be identified, quantified and
reported.
Details of significant impurities must include:
Names:
CAS number:
Quantity (S.I. units):
Maximum allowable limits:
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Confidential Appendix For all hazardous substances applications
3. Any other confidential information
Please use this section to provide any extra confidential information regarding your application.
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