DECLARATION FORM FOR
CHEMICAL PRODUCTS
PRODUCT REGISTER
Norwegian Environment Agency
Postboks 6257 Etterstad , 0603 Oslo
Telephone: + 47 73 58 05 00
Telefax: + 47 23 24 17 93
www.environmentagency.no
produktregisteret@miljodir.no
Shaded boxes to be completed by Product Register
Declaration no
1. Trade name for substance or mixture as shown on
the label:
2. Classification
Enter the classification either according to the Norwegian
Regulations relating to classification, labelling etc. of
dangerous chemicals or the Regulation (EC) No. 1272/2008
(CLP)
Symbol letter, R-phrases according to Chemical labelling
regulations:
No. of variants (for simplified declarations
only): ...................
Signal words, code for hazard pictograms and codes for
hazard statements according to CLP:
Mark if product is solely raw material:
Box 1: Concerning simplified declaration see guidelines
Labelled on the basis of tests?
3. Company responsible for filling out the declaration form:
company only)
Yes
No
Enterprise no. (Norwegian
____________________________________
Telephone
Address
____________________________________
E-mail
____________________________________
Box 3: Another company may fill out the declaration form, but the final legal responsibility rests with the first company in
Norway to import the chemical product. They will be legally responsible under the Norwegian law for the completeness and
accuracy of the information provided.
4. Quantities:
Tonnes/year
Figures for year:
Produced
Imported
Renamed
Exported
Box 4: Quantities in tonnes/year.
Telephone:
5. Manufacturer:
Company name:
Address:
E-mail:
Box 5: Give the name of the actual manufacturer of the chemical.
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Country:
6. Company name on label:
Name:
Address:
Box 6: Give
Telephone:
the name and address of the company in the EEA named on the label.
7. List of customers/Norwegian distributors:
Name
Address
Enterprise no
Telephone/E-mail
Box 7: If the company responsible for filling out the declaration form is not Norwegian, please give the name of the
Norwegian customer (first company in the chain of distribution) here. Append a separate list if there is too little space. The
Enterprise number should be available through your customer/distributor.
8. Branches of industry where the product is used (one line per branch):
Branch code
Are the chemicals also used for nonoccupational purposes? If « YES », give the
percentage of non-occupational purposes
PR1
YES :
NO :
%-distribution
Sum 100%
Give a description of the branches where the product is used:
Box 8: List the branches of industry that you consider to be the most important (use codes or key words) and % for each.
Unspecified branches should be < 20% of the total. Examples of branches of industry: 23.5, “Manufacture of cement,
lime and plaster” and 06, “Extraction of crude petroleum and natural gas”.
9. Product type (one line per product type):
Code
%-distribution
Sum
100 %
Description of the product type:
Box 9: List the product types that you consider to be the most important (use codes or key words) and % for each.
Unspecified types should be < 20% of the total. Examples of product types: “Cleaning product for floors” and H1520,
“Glue hardener”.
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10. Constituents of the chemical product:
Unambiguous chemical name/Raw material name
Identification number
No.
CAS-no.
EC-no.
/P-no.|
Are all the constituents given?
Function
(code)
Yes
Classification according to
the Norwegian regulation
relating to classification,
labelling etc. of dangerous
chemicals: Symbol letter,
R-phrases and Notes
No
Classification
according to CLP:
Hazard Class,
Hazard Category,
Hazard
statement
Code(s) and Notes
Given on
label?
(yes/no)
Sum weight
%
(=100)
Box 10: List all constituents with identity numbers (CAS/EC no.), unambiguous chemical names, functions in the chemical, classification and exact % by weight.
Raw materials may be listed with declaration numbers if available. Examples of functions are corrosion inhibitor, plasticizer, siccative, etc. Give any further
information on health and environmental risks in box 12. Constituents must be numbered (first column), as the numbers will be used for reference in any subsequent
correspondence. Append a separate list if there is too little space.
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Weight-%
11. Physical data:
Form/consistence:
Fast (briquettes/rods)
Tick here:
Partition coefficient (n-octanol/water):
Powder
Bio concentration factor (BCF):
Pasta
pH (as sold):
Liquid
Specific weight kg/m3:
Gas
Tick if the chemical contains nanomaterials:
Information about the content of nanomaterials that is known for the registrant should
be given. The definition of nanomaterials follows the EC Recommendation
2011/696/EU
Aerosol
Flash point oC:
(Mandatory for flammable liquids)
Method used
(CC/OC)
12. Other relevant information:
13. Confidentiality and signature:
In principle all information given to government authorities shall be available to the public. If some information
must be treated as confidential, please indicate the information you want to be treated as confidential. Information
available from other sources (e.g. safety data sheet or label) will normally not be confidential. Information that you want
to keep confidential has to be specified and argued for below in brief. A more thorough argumentation must be available
upon request from the Norwegian authorities. All information that is not specified as confidential will be treated as public
information.
Does this form have information that you want to keep confidential?
Yes
Protection of information is in accordance with the Norwegian Product Control Act.
No
How to understand the table below:
-Protection of trade name: The chemical shall not be linked to your company in any public information.
-Protection of quantities: Quantities shall not be public information except as part of anonymous statistics.
-Protection of manufacturer: Manufacturer is not to be identified to the public.
-Protection of Norwegian distributors: Distributors are not to be identified to the public.
-Protection of the composition: No part of the constituents is to be public information. If information about constituents
stated on a safety data sheet should be treated as confidential, this must be stated explicitly.
-If the information that the chemical contains nanomaterial should be treated as confidential, this must be stated here.
Subject
Trade secret
(tick box)
Reason why the information shall be kept confidential
Trade name
Quantities
Manufacturer
Norwegian
distributors
Constituents of
the product
Nanomaterials
I hereby confirm that the information given above is correct and will be updated regularly. I understand that all documents
of relevance to the completion of the declaration form shall be available in the company. The authorities may require such
documentation to be submitted on request.
For the company
Date:
TB-0800E
signature:
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