article 27 notification form - Environmental Protection Agency

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Article 27 notification form
ARTICLE 27 NOTIFICATION FORM
This form is for the
notification
of a
by-product decision
by an
economic operator
under article 27 of the
European Communities (Waste Directive) Regulations
(S.I. No. 126 of 2011)
-
The completed and signed form should be sent in hard copy to:
Article 27 Notifications
Environmental Licensing Programme
Environmental Protection Agency
PO Box 3000
Johnstown Castle Estate
Co. Wexford
OR
-
the signed document scanned and emailed as an attachment to:
licensing@epa.ie
(please write “Article 27 Notification” in the subject line of the email)
Version 1.2, 10 July 2013
1
Article 27 notification form
Preface – Please Read This First
Please read and understand the information in this preface before making your
notification to the Agency.
You (the ‘notifier’) have made a decision in accordance with article 27(1) of the
European Communities (Waste Directive) Regulations, 2011, that a material is to be
considered a by-product. You are notifying your decision to the Agency under article
27(2) of the Regulations. The Agency will enter your decision on a register. The
Agency is obliged under article 27(5) of the Regulations to maintain a register of
notified decisions. It is the policy of the Agency to make that register publicly
available and any information you provide on this form or in attached documents will
be available for public view in electronic format. Do not include or attach any
information that is confidential or that you do not wish to make public.
Any decision made by the Agency1 on foot of your notification will be based on
information provided by you, including this notification form and any attachments.
The Agency will also take into account any information provided by the relevant local
authority and other parties. The accuracy and legitimacy of the information provided
will be taken for granted unless there is reason to think otherwise. It will be assumed
that you are entitled to make a by-product decision on the material in question
unless there is reason to think otherwise. Any misrepresentation or omission of
information is your responsibility solely.
You should recognise that the by-product decision under article 27 is made by you
(the economic operator) – not the Agency. You are notifying the Agency of your
decision, not seeking a decision by the Agency. The decision you have made and are
notifying is your responsibility.
The Agency is entitled under article 27(3) of the Regulations to ‘determine’ that the
material you have notified as a by-product is in fact to be considered as waste. A
determination will in effect reverse the decision you made under article 27(1). You
will be consulted before the Agency makes such a determination.
You are not obliged to wait for feedback from the Agency before proceeding to
implement your own decision – that is, to manage the material as a by-product and
not a waste. However it may be appropriate to wait for the Agency’s feedback on
your notification if there is any risk that the Agency will determine that your material
is to be considered a waste.
The Agency can at any time determine that the material is to be considered as
waste. If at any time it becomes evident that:
-
you are not meeting any commitments you made in your notification,
you are departing from the grounds upon which you made your decision
under article 27(1) and notified it under article 27(2), or
the information you provided in your notification is false or misleading,
the Agency will determine that the material is to be considered as waste. You will be
consulted before the Agency makes such a determination. Any environmental liability
arising from incorrectly managing the material as a by-product and not a waste will
be the notifier’s and the notifier’s alone.
A number of notifications made previously to the Agency have involved materials
that are in fact products, not by-products. Notifiers should carefully consider, before
A decision made by the Agency might be a decision to determine that the material is a waste or
it might be a decision not to determine at a point in time that the material is a waste.
1
Preface – Read this first
2
Article 27 notification form
making a notification, whether their material is actually a product. The European
Commission has published guidelines on this matter in section 1.2 of the document
Guidance on the key provisions of Directive 2008/98/EC on waste, June 2012.
Notifiers should read this guidance before making a notification. The guidance is
available at:
http://ec.europa.eu/environment/waste/framework/pdf/guidance_doc.pdf
Notifiers should complete all parts of this form and all parts of each table. Attach
additional information as necessary to elaborate or provide additional detail.
The form is designed to assist economic operators in making a full notification. The
guidance notes provided in this form are for guidance only. The form is not intended
to be and should not be taken as a legal interpretation of the Regulations. If you are
unsure of your obligations under article 27, you should seek professional assistance
or legal advice.
For information, the full text of article 27 of the Regulations is reproduced here:
Article 27 of the European Communities (Waste Directive) Regulations, 2011 (S.I. No. 126 of
2011)
27. (1) A substance or object, resulting from a production process, the primary aim of
which is not the production of that item, may be regarded as not being waste
but as being a by-product only if the following conditions are met:
(a) further use of the substance or object is certain;
(b) the substance or object can be used directly without any further processing
other than normal industrial practice;
(c) the substance or object is produced as an integral part of a production
process; and
(d) further use is lawful in that the substance or object fulfils all relevant
product, environmental and health protection requirements for the specific
use and will not lead to overall adverse environmental or human health
impacts.
(2) (a) Where an economic operator makes a decision in accordance with
paragraph (1) that a substance or object is to be regarded as a by-product,
he or she shall notify the Agency of the decision and the grounds for the
decision.
(b) Where there is no notice given to the Agency under subparagraph (a) in
respect of a substance or object and the substance or object, as the case
may be, is discarded or otherwise dealt with as if it were waste, the
substance or object, as the case may be, shall be presumed to be waste
until the contrary is proved.
(3) The Agency (a) may determine, in consultation with the relevant local authority and the
economic operator concerned, whether a substance or object notified to it
as a by-product in accordance with paragraph (2)(a) should be considered
as waste, and
(b) shall notify the local authority and the economic operator concerned in
circumstances where a determination is made that a substance or object
should be considered as waste and not as a by-product.
(4) Nothing in this Regulation shall relieve an economic operator from his or her
responsibilities under the Act of 1992 or the Act of 1996.
Preface – Read this first
3
Article 27 notification form
(5) The Agency shall establish and maintain a register of by-products to record
substances or objects notified to it as by-products under paragraph (2)(a).
(6) Where the Agency makes a determination in accordance with paragraph (3) that
a substance or object should be considered as waste and not as a by-product,
the determination shall be final.
Preface – Read this first
4
Article 27 notification form
A. Identify the Economic Operator (the person or organisation making the
notification)
The economic operator named below has decided under article 27(1) of the Regulations that a particular
material and its use described in Sections B and C below is to be classified as a by-product.
Name of the economic operator *
(the individual, company or organisation
making this notification or for whom it is
being made)
Address of the economic operator
Name and address of the person
responsible for communicating with
the Agency on this notification **
Telephone number of contact
E-mail address of contact
Describe the economic operator’s
interest in the by-product (i.e.
generator, user, intermediary)
Was
an
Article
11
request
previously submitted in relation to
this by-product? If so, provide the
Article 11 reference number.
* The term “Economic Operator” is used in the Regulations but is not defined. For the
purposes of this notification form, it can mean the person/organisation generating the byproduct, the person/organisation using the by-product or the person/organisation handling
the by-product as an intermediary. It is generally taken to mean a person/organisation with
an economic interest in the by-product. It does not mean a consultant or other third party
representative of these persons/organisations.
** This can be the Economic Operator or an employee or representative (such as a
consultant).
Section A – Complete this for all notifications
5
Article 27 notification form
B. Identify the source and nature of the by-product being notified (the
activity and location where the by-product originates or is generated):
The economic operator identified in Section A above has made a decision that the material specified and
described below is a by-product that meets the requirements of article 27(1) of the Regulations.
Identify and describe the material
being notified as a by-product
(it will be possible to expand further on this
description later in the form)
Describe any hazardous
components in the notified material
(it will be possible to expand further on this
later in the form)
Identify and describe the process or
activity in which the by-product is
generated
(it will be possible to expand further on this
description later in the form)
Identify the location of the source
of the by-product
(factory/activity/development
and address)
-
name
Provide a contact name at the
source, including telephone number
and email address
If the source location has:




an IPPC licence,
a waste licence,
a waste facility permit, or
a certificate of registration,
provide the licence, permit or
certificate register number
Planning permission reference
number for source (most recent
permission)
Section C – Complete this for all notifications
6
Article 27 notification form
C. Identify the user of the by-product (the recipient activity):
The economic operator has made a decision that the by-product identified in Section B above will be
used as a by-product at the location and/or for the activity described below.
If more than one location or activity, copy and paste the table and complete it for each location and
activity, or alternatively provide a separate list of users and activities using the headings in the table
below. For soil and stone notifications, a separate notification form should be submitted for each
destination.
If there are no customers or outlets for the by-product, or if it is not commonly used for the proposed
use, this should be stated and further elaboration provided later in this form in relation to article
27(1)(a) regarding the certainty of use of the by-product. A lack of customers or outlets will generally be
regarded as a lack of certainty of use. If further use is not certain, there is the risk that the material
would be disposed of as waste.
Identify the location where the byproduct will be used
(factory/activity/development
and address)
-
name
Identify and describe the activity or
activities in which the by-product
will be used
Provide a contact name at the
destination, including telephone
number and email address
If the user of the by-product has:




an IPPC licence,
a waste licence,
a waste facility permit, or
a certificate of registration,
provide the licence, permit
certificate register number
or
Section C – Complete this for all notifications
7
Article 27 notification form
D. Additional information required for notification of SOIL and STONE and
similar material being used as BACKFILL or FILL for site restoration or
development:
This section is mandatory only for notifications involving:
-
topsoil,
subsoil,
stone,
mixtures of topsoil/subsoil/stone,
silt,
dredged material, and
other materials of this nature,
where these materials are intended for use in backfilling/filling operations and land
development activities, such as:
-
improvement and development of agricultural land,
development and landscaping of gardens and parks,
development and maintenance of roadside verges,
backfilling of disused quarries or mines,
construction of roads, and
other activities of a similar nature.
For all other notifications, proceed directly to section E of this form.
D.1 The source of the soil and stone (or similar material) is:
[Check the box appropriate to the source of the notified soil and stones in either greenfield or
brownfield sections below]
Uncontaminated land which has not been previously developed.
Uncontaminated overburden from mine or quarry sites.
Uncontaminated agricultural or forestry land.
Previously developed land (including land which is or was
occupied by a permanent structure and/or associated fixed
infrastructure).
Land with naturally elevated concentrations of metals.
Other – describe below or in an attachment (if not otherwise
adequately described in sections B and E of this form).
Section D – Complete this section for Soil and Stone (and similar materials)
notifications only
8
Article 27 notification form
D.2 Describe the source of the material as greenfield or brownfield
Greenfield site
Brownfield site
D.3 State the quantity of soil and stone (or similar material) being excavated and
deposited (in tonnes preferably or cubic metres alternatively)
{
Quantity of notified soil and stones to
be excavated from the source site and
deposited at the destination site
tonnes
Quantity of material already
deposited at the destination site*
tonnes
Quantity of material required to
complete the whole fill at the
destination site (including that
already deposited)
tonnes
m3
m3
m3
* If material was previously deposited, state whether as by-product or as waste by
completing (i) and/or (ii) as follows:
(i) Was by-product deposited?
Yes
No
State the notification number and provide the other information requested in the
table:
By-product notification
number
Date notified
Date the fill
commenced
Date the fill
completed
(ii) Was waste deposited?
Yes
No
State the type of waste authorisation and the register number of the authorisation.
Type of latest waste
authorisation (tick box)
Authorisation
register number
Grant date
Expiry date
Waste licence
Waste facility permit
Certificate of registration
Section D – Complete this section for Soil and Stone (and similar materials)
notifications only
9
Article 27 notification form
D.4 Confirm that the material is uncontaminated
Soil and stone (and similar material) sourced from greenfield or brownfield sites must
be uncontaminated and contain no other materials including, but not limited to,
construction and demolition materials. Confirm by ticking the box below.
The material notified is uncontaminated and contains no other materials
other than soil and stone or similar naturally occuring substances (tick
box)
D.5 Categorise the intended use of the notified material
Use in the improvement and
development of agricultural land
Use in the backfilling of disused
quarries or mines
Use in the development or
landscaping of parks and gardens
Use in the construction of roads.
Use in roadside verges
Other - describe below or in an attachment (if not otherwise adequately
described in section C and E of this form)
D.6 Maps showing source and destination locations
Provide a location map or maps showing the source and destination location
described in sections B and C above. Maps should be appropriately scaled –
maximum A3 size – showing the site locations in the context of their surroundings
and clearly highlighting the site boundary.
Map of source site attached (tick box)
Map of destination site attached (tick box)
State the six-digit Irish National Grid* co-ordinates for the source and destination
locations
Source site
E
N
Destination
site
E
N
Section D – Complete this section for Soil and Stone (and similar materials)
notifications only
10
Article 27 notification form
* A co-ordinate converter is available at http://gps.osi.ie/calculators/converter_index.asp.
D.7 Planning permission
Provide information on planning permission for the destination site where the
material will be used.
State whether, in relation to the destination site:
Planning permission was granted
Planning permission was refused
The proposal is Exempted Development
Provide the following information on any planning permission grant or refusal:
Planning File Ref. No.
Date of grant or
Date of expiry of
refusal
permission
State whether the planning permission authorises the fill/backfill part of the
development in question.
Yes
No
Information on planning permission is sought for the following reasons:
-
grant of planning permission might, but will not always, indicate that certainty
of use is possible;
-
refusal of planning permission will in general indicate that there can be no
certainty of use and that deposit of material is not lawful.
The Agency will not usually accept a notification that involves a fill activity that will
be carried on:
-
without planning permission; or
-
as exempted development.
In these circumstances it is likely that the Agency will refuse the notification and
make a determination that the notified material is a waste on the basis that,
amongst other things:
-
the activity might not be lawful,
there might be no certainty of use, and/or
it cannot be demonstrated that the fill/backfill activity will not lead to overall
adverse environmental or human health impacts.
Please do not submit any planning documentation with your notification. Your facts
will be checked with the planning authority.
D.8
Environmental Impact Assessment
Section D – Complete this section for Soil and Stone (and similar materials)
notifications only
11
Article 27 notification form
State whether the development at the destination site was subject to Environmental
Impact Assessment (EIA)
Yes
No
EIA is carried out by State bodies such as planning authorities, local authorities and
the EPA. An Environmental Impact Statement (EIS) is usually provided by a
developer/proposer and provides the information that enables the State body to
carry out the EIA. In the box below, provide the name of the State body that carried
out the Environmental Impact Assessment relating to the development in question:
State whether the EIA covers the fill/backfill activity and this activity was specifically
addressed in the Environmental Impact Statement
Yes
No
Please note that if Environmental Impact Assessment is required at the destination
site for the proposed fill/backfill activity, but has not been carried out, it is likely that
the Agency will refuse the notification and make a determination that the notified
material is a waste on the basis that it cannot be demonstrated that the fill/backfill
activity will not lead to overall adverse environmental or human health impacts.
Please do not submit an Environmental Impact Statement with your notification.
Your facts will be checked with the State body that carried out the EIA.
D.9
Appropriate Assessment and Natura Impact Statement
State whether Screening for Appropriate Assessment was carried out in relation to
the destination site and, in particular, the fill/backfill activity
Yes
No
State whether the development at the destination site was subject to Appropriate
Assessment in accordance with the requirements of article 6 of the Habitats Directive
Yes
No
Not required based on the findings of a Screening for Appropriate Assessment
Appropriate Assessment is carried out by State bodies such as planning authorities,
local authorities, NPWS, the EPA. A Natura Impact Statement (NIS) is usually
provided by a developer/proposer and the NIS provides the information that enables
the State body to carry out Appropriate Assessment. In the box below, provide the
name of the State body that carried out the Appropriate Assessment or made the
decision, based on a Screening for Appropriate Assessment, that none was required
in relation to the fill/backfill development:
Section D – Complete this section for Soil and Stone (and similar materials)
notifications only
12
Article 27 notification form
State whether the Appropriate Assessment covered the fill/backfill activity and that
this activity was specifically addressed in the Screening for Appropriate Assessment
and/or the Natura Impact Statement (or the Environmental Impact Statement if this
was used for the Appropriate Assessment)
Yes
No
For all developments, a “Screening for Appropriate Assessment” report will have
been carried out in relation to the fill activity. A Natura Impact Statement (NIS)
might also have been prepared for consideration by a planning/public authority2 as
defined in Regulation 2(1) of the European Communities (Birds and Natural Habitats)
Regulations 2011 (S.I. No. 477 of 2011).
Please note that if a Screening for Appropriate Assessment has not been carried out,
it is likely that the Agency will refuse the notification and make a determination that
the notified material is a waste on the basis that it cannot be demonstrated that the
fill/backfill activity will not lead to overall adverse environmental or human health
impacts.
Please note that if Appropriate Assessment is required at the destination site, but has
not been carried out, it is likely that the Agency will refuse the notification and make
a determination that the notified material is a waste on the basis that it cannot be
demonstrated that the fill/backfill activity will not lead to overall adverse
environmental or human health impacts.
Please do not submit any Appropriate Assessment documentation with your
notification. Your facts will be checked with the State body that carried out the
Appropriate Assessment or determined that none was required.
D.10 Suitability of the material for the intended use
The notified soil and stones (or similar material) must be suitable for the intended
use in the development activity. Provide signed documentation from a suitably
qualified person (e.g. chartered engineer) as to the suitability of the notified material
for the purposes of the development.
Attached is a qualified person’s sign-off on the suitability of the notified
material for the development/use proposed (tick box)
The sign-off explains the reasons why the notified material is suitable for
the development/use proposed (tick box)
Failure to tick both boxes and attach the relevant document is likely to result in a
notification being refused and a determination being made under article 27(3)(a) of
the Regulations stating that the notified material is in fact a waste.
2
This might be the Agency in the case of, for example, a waste licence application.
Section D – Complete this section for Soil and Stone (and similar materials)
notifications only
13
Article 27 notification form
E. Address the conditions for being a by-product:
Article 27(1) of the Regulations (reproduced above) states that a substance or object
resulting from a production process the primary aim of which is not the production of
that item may be regarded as being a by-product if the conditions set out in article
27(1)(a) to (d) are met.
An arrow in this section () indicates information to be provided.
The European Commission has clarified the concept of “by-product” in Guidance on
the interpretation of key provisions of Directive 2008/98/EC on waste, June 2012,
and the following is an extract of text from that guidance:
 Product – all material that is deliberately created in a production process. In many
cases it is possible to identify one (or more) “primary” products, this or these being the
principal material(s) produced.
 Production residue – a material that is not deliberately produced in a production
process but may or may not be a waste.
A production residue that fulfils the requirements of Article 5 [Waste Framework
Directive] is a by-product.
Is the material concerned a production residue or a product?
A production residue is something other than the end product that the manufacturing
process directly seeks to produce. Where the production of the material concerned is
“the result of a technical choice”, it cannot be a production residue and is considered a
product.
If the manufacturer could have produced the primary product without producing the
material concerned but chose not to do so, this is evidence that the material concerned
is a product and not a production residue. Also a modification of the production
process in order to give the material concerned specific technical characteristics could
indicate that the production of the material concerned was a technical choice.
Before addressing items (a) to (d) below, see if your by-product decision meets the
basic concept for by-product, as follows:
1. Write in the space below the name or description of the production process
___________________________________________________________________
2. Write in the space below the name or description of the material to be notified as a
by-product.
___________________________________________________________________
3. Is it the primary aim of the production process (item 1) to produce the material
mentioned in item 2?

Yes/No
If the answer to question 3 is “yes”, then your material might not be a by-product,
but a product.
Section E – Complete this for all notifications
14
Article 27 notification form
Only if the answer to question 3 is “no” should you test your material against the
conditions in article 27(1)(a) to (d) and proceed to complete the rest of this form.
You might also wish to ask yourself whether your material is currently classified as
waste, or would be classified as waste under normal circumstances. If the answer to
this question is “no”, this might indicate that your material is a product. As noted
earlier in this form, it can be foreseen that difficulties would arise for notifiers that
notify a “product” as a by-product but the Agency decides that the material should be
classified as a waste.
Address each of the following four conditions in full. Attach all relevant supporting
information. Failure to address each of the four items in full could result in a
determination being made that the notified by-product is to be considered as waste.
The notes provided below the conditions are intended as guidance only.
Section E – Complete this for all notifications
15
Article 27 notification form
Article 27(1)(a) – further use of the substance or object is certain
This means that further use is not a mere possibility, but a certainty or it is guaranteed that the material
will be used. The purpose of this criterion is that, if further use is not certain, there is the risk that the
material would be disposed of as waste. It may be possible to show certainty of use through, for
example:
-
existence of contracts between the waste holder and subsequent user;
a financial gain for the waste holder; or
a solid market existing for the further use.
The European Commission’s Guidance on the interpretation of key provisions of Directive 2008/98/EC on
waste elaborates further on this condition.
Storage of the notified material while customers are found for it does not indicate that further use is
certain. You have provided above the name and address of one or more users of the by-product.
Elaborate on the use of the by-product in the box below.

<expand box or use an additional sheet as necessary>
Section E – Complete this for all notifications
16
Article 27 notification form
Article 27(1)(b) – the substance or object can be used directly without any further
processing other than normal industrial practice
The Agency generally accepts that ‘normal industrial practice’ can comprise such activities as screening,
crushing, grading, dewatering – this is a guideline, not a rule.
The European Commission’s Guidance on the interpretation of key provisions of Directive 2008/98/EC on
waste elaborates further on this condition.
Elaborate in the box below on what further processing, if any, is carried out on the substance or object,
and at what location, prior to it being used as a by-product. Explain why you consider this should be
considered to be ‘normal industrial practice’ for your sector or activity.

<expand box or use an additional sheet as necessary>
Section E – Complete this for all notifications
17
Article 27 notification form
Article 27(1)(c) – the substance or object is produced as an integral part of a
production process
This links to the logic test you employed above. The production process does not have as its primary aim
the generation of this material, but the generation of the material is an integral part of the production
process.
The European Commission’s Guidance on the interpretation of key provisions of Directive 2008/98/EC on
waste elaborates further on this condition.
Elaborate on this question in the box below.

<expand box or use an additional sheet as necessary>
Section E – Complete this for all notifications
18
Article 27 notification form
Article 27(1)(d) – further use is lawful in that the substance or object fulfils all
relevant product, environmental and health protection requirements for the specific
use and will not lead to overall adverse environmental or human health impacts
In the box below, identify all product, environmental and health protection requirements that relate to
the by-product and its placing on the market. State how the notified by-product meets those
requirements. Indicate any limitations or prohibitions on the use of the by-product in the use proposed.
If there are no relevant technical specifications, say so.
In your thinking on this item, do not consider the material as a waste or apply what you would
understand to be waste-like controls to the material. Instead, you are proposing that the material is not
a waste. It is therefore subject to the wide range of international, European and national legislation on:
-
marketing and placing on the market of products (e.g. REACH, CLP, GHS)
transport and storage
planning permission
The Agency may decide to consult with relevant regulatory authorities to check claims made by notifiers
in this section.
Referring to the final clause of the sub-article, you must demonstrate that the use of the by-product will
not cause environmental pollution or impact on human health during its transport, storage and use.
In relation to notifications involving soil and stone, such demonstration should be in the
form of an environmental assessment carried out at the destination site. Acceptable forms
of environmental assessment are:
-
Environmental Impact Assessment (see section D.8 above);
Grant of waste facility permit or waste licence; and
For soil and stone deposition sites where the total lifetime fill is less than 25,000
tonnes, grant of planning permission.
Other forms of environmental assessment will not generally be accepted.
Notifiers should also provide comprehensive information on the manner in which any potential
environmental impacts will be mitigated and monitored, and what actions will be taken in the event of
an incident that results in environmental pollution being caused.
The European Commission’s Guidance on the interpretation of key provisions of Directive 2008/98/EC on
waste elaborates further on the different aspects of this condition.
Elaborate on these issues in the box below.

<expand box or use an additional sheet as necessary>
Section E – Complete this for all notifications
19
Article 27 notification form
DECLARATION
I hereby notify the Environmental Protection Agency pursuant to Article 27(2)(a) of
the European Communities (Waste Directive) Regulations, 2011, of my decision that
the substance/material described above is a by-product within the meaning of Article
27(1) of the Regulations.
I declare that the information given in this notification is truthful, accurate and
complete and is a full and complete representation of the substance/material notified
and its proposed use.
I make this notification on the understanding that an incomplete, misleading or
otherwise falsified submission will not be regarded as a notification for the purposes
of Article 27(2)(b) of the Regulations and that in such circumstances, the
substance/material notified may be determined to be a waste and consequently any
use of the substance/material may be regarded as a waste activity.
I declare that the proposed use of the notified substance/material fulfills all relevant
environmental and health protection requirements and that the proposed use is
lawful and complies with the provisions of any and all relevant legislative
requirements.
I make this notification on the understanding that, in accordance with the provisions
of Article 27(3)(a), the EPA may determine at any time that the substance/material
notified herein as a by-product is to be considered a waste and that any
determination made by the EPA that said substance/material is a waste and not a
by-product is final.
I have read and understood the preface to this document and other guidance
contained in the document.
I am authorised and/or entitled to make this notification.
Signed:
Date:_____________
(by or on behalf of the economic operator)
Print your name:
Position in organisation:
Organisation/Company:______________________________________________
Company Seal:
Declaration – Complete this for all notifications
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