Dear Supplier,
Arkema Inc. is committed to excellence in all aspects of its business. Arkema is dedicated to
not only exceeding our customer’s expectations, but also to continuous improvement in our
supply chain processes.
As a supplier to Arkema, you are key to the success of our supply chain. We consider
excellence in Health, Safety, Environmental and Security performance a core value of a
successful supply chain and expect our suppliers to embrace these same values. Arkema also
expects both itself and its suppliers to continuously improve the supply chain by optimizing
value based upon the principles of quality management.
As part of Arkema’s commitment to the principles of the American Chemistry Council’s
Responsible Care program and our drive for continuous improvement, you will find included
with this letter a supplier evaluation questionnaire. Please complete the questionnaire and return
via email or parcel post within 15 days of receipt to the location listed on the survey. We will
contact you to discuss and resolve any open issues within 30 days of receiving the completed
survey.
Below is a checklist of required documents to be returned:
1.
Supplier Assessment Questionnaire
2.
Regulatory Status Certification Questionnaire for each supplied raw material
3.
MSDS for each supplied raw material
4.
Copy of any certifications ( NACD, ISO, etc)
5.
Copy of Harmonized Tariff Code and/or NAFTA Certificate including Country
of Origin.
6.
Copy of specification for packaging (ISO, IBC, or Drum) that will be used to
ship raw material
Arkema would like to thank you in advance for your assistance and prompt reply. If you have
any questions regarding the survey or are unable to meet the survey deadline, please contact
Cindi Brodsky at 610-205-7068 or Kim Koellner at 610-205-7112.
Sincerely,
Richard Rennard
Richard Rennard
Director, Raw Materials, Energy and Packaging
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Arkema Inc. Supplier Assessment
Instructions:
This survey is intended to be completed electronically and emailed back to the Arkema
Inc. contact person listed at the end of the survey. You may also choose to print out the
survey, complete it and return by parcel post or fax to the same contact person.
The survey is divided into 3 sections: General Information, HESS Management System
Information and Quality Management System Information.
This survey is part of Arkema Inc.’s supplier management program. Arkema’s program
includes assessment and qualification protocols for both the supplier of the raw materials
and the raw materials themselves and provides for periodic review and re-qualification of
our vendors and their materials supplied to Arkema Inc.
Please use the drop down menus for your YES or NO answers.
Section A – General Information
Completed _________
Date
Company Name:
Address:
Telephone:
D&B Number:
Employees:
Annual Sales:
Person responsible for
completing questionnaire:
Title:
Telephone:
E-mail address:
Signature
1. Is your company a member of American Chemistry Council, CCPA, SOCMA, CEFIC,
NACD or another organization committed to Responsible Care®?
Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
2. If YES, please identify the organization below.
3. Please provide the following financial information:
a.



Bank Reference(s):
Most Recent Annual Report
If publicly traded, on which exchange(s)? :
Symbol for the above exchange(s):
4. Please provide updated Material Safety Data (MSDS) and Technical Data Sheets (TDS)
or Specifications for the chemicals supplied by your company to Arkema Inc. If these
are available online, please provide the web address or link.
Web Address/Link:
5. Provide the name and address of the manufacturing location for this raw material(s).
6. Arkema’s records show that your company supplies the following chemicals to the
following Arkema locations. Please update the information in the table below or attach
the update separately.
Chemical Supplied
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Arkema Location
Supplier Location
Comments
If you answered YES to question 1, skip to section C – Cooperative Assistance.
If you answered NO to question 1, please answer all questions in Section B – Health,
Environment, Safety and Security
Section B – Health, Environment, Safety and Security (HESS)
7. Is your company a member of another organization that practices similar principles of
good product stewardship?
Answer
If YES, please identify the organization below and attach a copy of their guiding
principles.
8. Does your organization have a written health, environment and safety policy, guiding
principles or other document?
Answer
9. Are there specific individuals in your organization with the responsibility for managing
the HESS effort?
Answer
If YES, please provide name(s) and title(s) as a contact.
Name
Title
Name
Title
10. Do you have a system in place that measures the progress of your HESS efforts?
Answer
11. Do you have a process for the development of information on potential hazards and risks
associated with the manufacture and use of your products?
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Answer
12. Do you conduct a formal documented HESS review of each product prior to approval for
commercialization?
Answer
13. Do you have a process to survey or audit the following for their commitment to the
principles of product stewardship?
a.
b.
c.
d.
Contract Manufacturers
Suppliers
Distributors
Customers
Answer
Answer
Answer
Answer
14. Do you have HESS training programs in place for all employees based on job function?
Answer
15. Do you have a process in place to communicate hazard/risk information to:
a.
b.
c.
Employees
Customers
Communities near your facility
Answer
Answer
Answer
16. Do you have written procedures to manage the following:
a.
b.
c.
d.
e.
f.
g.
h.
Chemical hazards and exposures
Emergency response
Chemical handling
Standard operating procedures
Worker protection
Raw material and product storage
New or modified products
New or modified processes
Answer
Answer
Answer
Answer
Answer
Answer
Answer
Answer
17. Do you have a process to audit for compliance with these procedures?
Answer
18. Do you have written procedures to ensure compliance with applicable HESS laws and
regulations?
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Answer
19. Does your company have a procedure to conduct evaluations of the potential impact of
releases on the environment and the health and safety of employees and the public?
Answer
20. Do you have a procedure or system for the establishment of priorities, goals, and plans
for waste and release reduction?
Answer
Comments
21. Do you have an ongoing program for addressing past operating and waste management
practices and for working with others to resolve identified problems?
Answer
Section C – Cooperative Assistance
22. Is there any additional information about your company’s commitment to product
stewardship that you wish to describe?
Answer
If YES, please describe
23. Is there anything that we can do to assist you with implementation of your product
stewardship program?
Answer
If YES, please describe and identify a contact person:
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Section D – Business Partner Security Questions
FOR SUPPLIERS THAT ARE IMPORTING MATERIAL INTO THE U.S.
(If you do not import materials skip to question 42)
Provide copy of specification for packaging (ISO, IBC, or Drum) that will
be used to ship raw material(s).
24. Are you members of C-TPAT?
Answer
If YES, please list and provide a copy of certification
If you answered YES, then the following questions are optional and you may skip to
Section E – Quality Management Systems
If you answered NO, then please complete the following questions:
For those business partners not eligible for C-TPAT certification, please demonstrate
you are meeting C-TPAT security criteria by supplying a written/electronic confirmation
of contractual obligations via a letter from a senior business partner officer attesting to
compliance; a written statement demonstrating compliance with C-TPAT security
criteria or an equivalent WCO accredited security program administered by a foreign
customs authority; or by answering an importer security questions listed below.
25. Do you have a seal integrity program to protect against the introduction of unauthorized
material and/or persons at the point of stuffing?
Answer
26. Do you have written and verifiable processes for the selection of business partners,
including manufacturers, product suppliers, and vendors?
Answer
27. Do you ensure that business partners develop security processes and procedures
consistent with the C-TPAT security criteria to enhance the integrity of the shipment at
the point of origin?
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Answer
28. Do you conduct periodic reviews of your business partners' processes and facilities based
on risk?
Answer
29. Do you require that current or prospective business partners, who have obtained a
certification in a supply chain security program being administered by a foreign customs
administration, indicate their status of participation?
Answer
30. Do you have an employee, visitor, and vendor identification system, including the
control of issuing and removal of identification badges, for the purpose of positive
identification and access control?
Answer
31. Do you have procedures to verify application information, including employment
history, references, background checks, and other applicable pre-employment
investigations, prior to employing an applicant?
Answer
32. Do you have procedures to ensure that information received from business partners
(carriers, contractors, suppliers, etc.) is reported accurately and timely?
Answer
33. Have your employees been made aware of the procedures the company has in place to
address a situation relating to a breach in security, including how to report the situation
and what to do in the situation?
Answer
34. Does the perimeter fencing at your facility(ies) enclose the areas around cargo handling
and storage area facilities and is the fencing regularly inspected for integrity and
damage?
Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
35. Are the gates through which vehicles and/or personnel enter or exit manned and/or
monitored?
Answer
36. Are private passenger vehicles prohibited from parking in or adjacent to cargo handling
and storage areas?
Answer
37. Do management or security personnel control the issuance of all locks and keys at your
facility or facilities?
Answer
38. Is adequate lighting provided inside and outside of your facility or facilities?
Answer
39. Are alarm systems, video surveillance cameras, and/or guards utilized and monitored to
prevent unauthorized access to cargo handling and storage areas?
Answer
Do your information technology systems:
40. Use individually assigned accounts that require a periodic change of password?
Answer
41. Identify any abuses, including improper access, tampering, and/or the altering of
business data?
Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
FOR U.S. DOMESTIC SUPPLIERS
Provide copy of packaging specification (ISO, IBC, or Drum) that will be
used to ship raw material.
Provide name of carrier if material is bulk shipped.
42. Are you members of C-TPAT?
Answer
If YES, please send a copy of your C-TPAT certificate for our files.
43. Do you transport DOT regulated hazardous materials
Answer
44. Do you abide by 49 CFR Security Plan requirements?
Answer
45. Are you are a member of American Chemistry Council, CCPA, SOCMA, CEFIC,
NACD or another organization committed to Responsible Care®?
Answer
If you answered YES to any of the above, skip to section E – Quality Management
Systems.
If you answered NO to all of the above, please answer the following:
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
46. Do you have a security plan / program?
Answer
If yes, please check off below which of the American Chemistry Council's (ACC) 13
Security Management Practices your plan adheres to, or submit written/electronic
confirmation of contractual obligations via a letter from a senior business partner
officer attesting to compliance; a written statement demonstrating compliance with CTPAT security criteria or an equivalent WCO accredited security program
administered by a foreign customs authority.
47. Mgmt Practice #1 - Leadership Commitment Answer
48. Mgmt Practice #2 - Analysis of Threats, Vulnerabilities and Consequences Answer
49. Mgmt Practice #3 - Implementation of Security Measures Answer
50. Mgmt Practice #4 - Information and Cyber Security. Answer
51. Mgmt Practice #5 - Documentation Answer
52. Mgmt Practice #6 - Training, Drills and Guidance Answer
53. Mgmt Practice #7 - Communication, Dialogue and Information Exchange Answer
54. Mgmt Practice #8 - Response to Security Answer
55. Mgmt Practice #9 - Response to Security Incidents Answer
56. Mgmt Practice #10 - Audits Answer
57. Mgmt Practice #11 - Third Party Verifications Answer
58. Mgmt Practice #12 - Management of Change Answer
59. Mgmt Practice #13 - Continuous Improvement Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Section E - Quality Management Systems
60. Do you have any third party certifications such, as ISO-9000, or other
standard or quality control assurance certifications?
management
Answer
If YES, please list and provide a copy of certification
If you answered YES, then the remainder of the questionnaire is optional. If you answered NO,
then please complete the following sections F through L.
Section F - Quality System Organization / Management
61. Does your Company and/or this facility have a formal, documented Quality Assurance
Policy, emphasizing the philosophy of continuous improvement and focused on
conformance to customer expectations?
Answer
62. Do you maintain records that provide evidence of conformity to the requirements and of
effective operation of your quality system?
Answer
63. Do you conduct internal audits at planned intervals to determine whether or not the
quality system conforms to the quality system requirements established by the
organization and is effectively implemented and maintained?
Answer
64. Does your company's top management ensure that the integrity of the quality system is
maintained when changes to the system are planned and implemented?
Answer
65. Are authorities and responsibilities for prompt, effective resolution of quality related
issues and quality planning clearly defined?
Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
66. Does your organization have procedures and processes to take action to eliminate the
causes of nonconformities and to ensure that the corrective actions are appropriate to the
effects of the nonconformities?
Answer
Section G - Control of Purchased Materials
67. Do you utilize a documented system for assessment of your suppliers, including
surveys/audits and corrective action records?
Answer
68. Do you verify that quality-critical materials you receive conform to your specifications?
Answer
69. Do you segregate non-conforming products received, and have a procedure for timely
disposition?
Answer
Section H - Loading and Shipping
70. Do your loading instructions include inspection of empty container (tank trucks, cars,
etc.) prior to filling?
Answer
71. Do you inspect filled containers prior to shipment for proper packaging and labeling, and
compliance with the customer's purchase order specifications?
Answer
72. Do shipping personnel have access to customer specifications?
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Answer
73. Are the above inspections documented or recorded?
Answer
74. Do you notify customers in the event of a delayed or late shipment?
Answer
Section I - Control of Measuring and Test Equipment
75. Does your system include periodic, recorded inspection and calibration of quality critical
measuring/testing equipment and standards in your process area, quality control lab, and
in other support services at your facility?
Answer
76. Are the precision parameters clearly defined, and records periodically reviewed to
determine if corrective action, revision or improvement is required or possible?
Answer
77. Is a corrective action system in place that addresses control of product potentially
affected by mal-functioning equipment or erroneous measurements?
Answer
Section J - Process Control and Capability Criteria
78. Do you have written, controlled operating procedures and instructions, with a system for
their evaluation and revision? Are your operators and other process employees trained
on these instructions?
Answer
79. Do you utilize a statistical process control system to identify and control your process
capability?
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Answer
80. Can you generate statistical quality control charts on the products you supply to
Arkema?
Answer
81. Can you supply a certificate of analysis, which shows conformance to Arkema’s
specifications with each shipment?
Answer
82. Can you demonstrate efforts to reduce variations and out-of-control points in your
process?
Answer
Section K - Final Product Testing and Acceptance
83. Do you have written procedures for sampling, testing and recording results of final
product's compliance with specifications prior to shipment?
Answer
84. Are the quality parameters of your testing lab documented and controlled (e.g.
instruments, standards, training of personnel)?
Answer
85. Does your procedure include methods for identification, segregation, and disposition of
non-conforming product?
Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Section L - Control of Off-Spec Finished Goods
86. Does your quality system include criteria for the identification, segregation and
disposition of off-spec product, to ensure that none of the off spec product is shipped to a
customer in error?
Answer
87. Is someone designated the responsibility to periodically review the status of these
products and follow up on corrective action items? Is this recorded?
Answer
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Logistics Information Requested
Provide a vendor transportation
regulatory contact.
Provide the requested information or provide link / attachment
Name:
E-mail
Phone
Fax
Provide Compliance Contact
(import/export):
Name:
E-mail
Phone
Fax
Provide the shipping description if
the material is a dangerous good.
UN Number
Shipping Name
Hazard Class
Packing Group
Technical
Ingredient(s)
Please provide the description and
packaging type the material will be
shipped in, including specifications
(ie., isotank, drum, ibc, bulk tank
truck, etc.) - Attach copies.
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
List material country of origin (if not
already supplied through NAFTA
Certification).
Provide name of carrier if material is
bulk shipped.
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
REGULATORY STATUS CERTIFICATION FORM FOR
SUPPLIED MATERIALS
Supplied Product Identity
(Trade Name)
Supplied Product Code
(Identifier)
Manufacturer / Distributor Name
Supplier: Please complete this form and return along with the below listed documents.
Failure to complete and return this form will disqualify you as an approved
supplier.
Documents to be provided for the supplied product:
 Safety Data Sheet (European (SDS) and US (MSDS) format, if available (not older than 3 years)
 Technical Data Sheet
 Specification Sheet (if different from the Technical Sheet)
NOTE: This information must be resubmitted upon changes in product composition or legislation.
I. Composition Information
Complete this section for all components of your product. 100% of the product composition must be accounted
for.
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Component (Chemical Name)
CAS Number, Accession
Number, or PMN Number
(when available)
Concentration
(% by wt.)
Total
100%
(Attach continuation page, if needed)
For each chemical component listed above, please respond to the following:
II.
Chemical Inventory Information
a.
Please indicate if the product supplied is in compliance with the following regulations:
Region/Country
Australian Inventory of Chemical
Substances (AICS)
Canadian Domestic Inventory (DSL)
Canadian Non-domestic Inventory
(NDSL)
China Inventory of Existing Chemical
Substances (IECSC)
European EINECS Inventory
European ELINCS Inventory
European No Longer Polymers List
Japanese Inventory of Existing & New
Chemical Substances (ENCS)
Korean Inventory of Chemicals
(KECI)
Philippine Inventory of Chemicals and
Chemical Substances (PICCS)
New Zealand Inventory of Chemical
Substances (NZIoC)
Swiss Inventory (Switzerland)
Additional Comments:
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Comment/exempt
Yes
No
Unknown
Yes
Yes
No
No
Unknown
Unknown
Yes
No
Unknown
Yes
Yes
Yes
Yes
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Region/Country
b.
Comment/exempt
U.S. Toxic Substances Control Act (TSCA) Status
i.
Inventory Status
Are all components of this product on the TSCA Inventory?
Yes
No
If No, provide explanation:
ii.
Specific TSCA requirements
Specific TSCA Requirements - Please indicate, by checking the applicable boxes, if this material
is subject to or is notified under any of the following TSCA requirements of 40 CFR. If the
product contains more than one substance, please identity the substance(s) to which each
section applies.
40 CFR
704
Section 8(a) - Chemical Specific
Reporting and Record-keeping
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
707
Section 12(b) - Export Notification
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
712
Section 8(a) - Chemical Information
Reporting
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
716
Section 8(d) - Health & Safety
Reporting
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
720.30
Section 5 - Premanufacture
Notification
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
720.36
Section 5 - R&D Exempt
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
721
Section 5 - Significant New Use
Subject to Regulation
Not Subject to Regulation
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
40 CFR
If subject, list chemical(s):
723.50
Section 5 - Low Volume/ LoREX
Exempt
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
723.250
Section 5 - Polymer Exempt
If subject, list chemical(s):
Subject to Regulation
Not Subject to Regulation
iii.
Is this material distributed under any special limitations such as TSCA section 5(e), 5(f)
or section 6 rule or Consent Order? If Yes, provide explanation. Yes
No
iv.
Have any 8(e) submissions been made on this product or any of its components?
If Yes, provide explanation.
Yes
No
c.
EU REACH Status
Confirm that your material is REACH
pre-registered
Confirm that your material is REACH
registered
III.
Yes
No
Comment
Yes
No
Comment
Other US Federal Regulations
a. Occupational Safety and Health Act (OSHA) Hazard Classification (29 CFR §1910.1200) check all that apply.
i. Immediate (acute) health hazard
ii. Delayed (chronic) health hazard
iii. Fire hazard
iv. Sudden release of pressure
v. Reactive
b. Please indicate if the product supplied contains any substances subject to the following
regulations.
Regulation
Clean Air Act: Section 112 EPA
Hazardous Air Pollutants (40 CFR 61)
Clean Air Act: Section 602 OzoneDepleting Substances (40 CFR 82,
Subpart A, Appendices A and B)
Clean Air Act: Section 112(r) Accidental
Release Prevention- Regulated Toxic or
Regulated Flammable Substances (40
CFR 68.130)
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Specify (regulated component(s))
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Regulation
Commerce Control List: Chemicals,
that may be used as Precursors for
Toxic Chemical Agents (15 CFR 774,
Supp. No. 1)
The Emergency Planning and
Community Right-to-Know Act:
Section 302 Extremely Hazardous
Substances (40 CFR 355, Appendix
A)
The Emergency Planning and
Community Right-to-Know Act:
Section 304 Release of Extremely
Hazardous Substances (40 CFR 355,
Appendix A; 40 CFR §302.4).
The Emergency Planning and
Community Right-to-Know Act:
Section 313 Toxic Release Inventory
Chemical (40 CFR 372)
U.S. Drug Enforcement
Administration: Listed Precursor and
Essential Chemicals (21 CFR
1310.04(f)) [List 1 and List 2].
Additional Comments:
IV.
Specify (regulated component(s))
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
U.S. State Right to Know Regulations
Please indicate if the product supplied contains any substances subject to the following
regulations.
State Regulation
California Proposition 65 Carcinogens
& Reproductive Toxins ("Chemicals
Known to the State to Cause Cancer
or Reproductive Toxicity", Cal. Code
Regs. tit. 22, sec. 12000).
Massachusetts Right-to-Know
Substance List (Mass. Gen. Laws
Ann. ch. 111F).
New Jersey Community Right-toKnow Table, Environmental
Hazardous Substances (EHS) List
(N.J. Admin. Code tit. 7, sec. 1G-2.1)
(provide NJ TS Number, if applicable)
New Jersey Right-to-Know
Substances (N.J. Stat. Ann. Section
34:5A-5). (provide NJ TS Number, if
applicable)
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Specify (regulated component(s))
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
State Regulation
Pennsylvania Right-to-Know
Hazardous Substances (34 Pa. Code
Chap. 301-323).
Additional Comments:
V.
Specify (regulated component(s))
Yes
No
Unknown
Presence of European Union regulated substances
Does the supplied product contain substances listed in the following regulations?
European R. 1272/2008, Annex VI,
Yes
No
Unknown
relating to carcinogenic, mutagenic and
reprotoxic substances?
European Regulation 552/2009 amending
Yes
No
Unknown
the annex XVII of Regulation 1907/2006
and repealing and replacing the Directive
76/769 relating to restrictions on
marketing and use of certain dangerous
substances and preparation
European Regulation 1907/2006, art. 59:
Yes
No
Unknown
Candidate list of substances (Annex XIV)
« Very High Concern » subjected to
restrictions?
European Regulation no. 2037/2000,
Yes
No
Unknown
Annex I on substances that deplete the
ozone layer (Montreal protocol)?
European Regulation No 842/2006 Annex Yes
No
Unknown
I on certain fluorinated greenhouse gases
(Kyoto protocol)
European Regulation No 689/2008
Yes
No
Unknown
concerning the export and import of
dangerous chemicals (Rotterdam
convention)
European Regulation No1334/2000 setting Yes
No
Unknown
up a Community regime for the control of
exports of dual-use items and technology
European Regulation No 273/2004 on
Yes
No
Unknown
drug precursors
VI.
Other European information
European D. 76/768/EC relating to
cosmetic products
European D. 98/8/EC concerning the
placing of biocidal products in the market
European Regulation No 648/2004 and its
amendments on detergents
European D. 94/62/EC on packaging and
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Matching the
criteria
Matching the
criteria
Matching the
criteria
Matching the
Not matching
the criteria
Not matching
the criteria
Not matching
the criteria
Not matching
Unknown
Unknown
Unknown
Unknown
packaging waste
European D. 2000/76/EC concerning
the incineration of waste
European Directive 2000/53/EC on
end-of life vehicles
European Directive 2002/95/EC and its
amendments concerning RoHS
European Directive 2002/96/EC
concerning WEEE
criteria
Matching the
criteria
the criteria
Not matching
the criteria
Matching the
criteria
Not matching
the criteria
Unknown
Matching the
criteria
Not matching
the criteria
Unknown
Matching the
criteria
Not matching
the criteria
Unknown
Unknown
European D. 1999/13/EC (and its
amendments) on the limitation of COV?
Swiss law 814.018 concerning the VOC?
Matching the
Not matching
Unknown
criteria
the criteria
Matching the
Not matching
Unknown
criteria
the criteria
European Regulation 850/2004 on
Matching the
Not matching
Unknown
persistent organic pollutants?
criteria
the criteria
Do you guarantee that this product does not contain substances answering simultaneously the
Yes
following conditions (Standard EN 13428 of October, 2004): 1) Dangerous for the
environment classified N according to the Directive 67/548/EEC and its amendments. 2)
Intentionally introduced for the functionality. 3) Susceptible to be released into the
environment during incineration or during its disposal on land?
VII.
Regulations concerned in China (Import/Export)
Regulation on the Administration of
Precursor Chemicals
(非药品类易制毒化学品生产、经营许
可办法)
Administration Regulation on Controlled
Chemicals (CWC-中华人民共和国监控化学品管理条例)
Ozone Destroy Chemicals
(中国进出口受控消耗臭氧层物质名录
(第一，二，三，四批))
TOXIC CHEMICAL that is controlled
strictly when import/export
(中国严格限制进出口的有毒化学品目
录（2009版）)
Import Forbidden/Export Forbidden
(禁止进口货物目录（6批）禁止出口货
物目录（5批）)
Hyper Toxic Chemicals
(剧毒化学品目录)
Dual-use items
(两用物项和技术进出口许可证管理办
法2009)
Machining Commerce Forbidden List
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
No
(加工贸易禁止类商品（2009）)
Machining commerce Restricted List
(加工贸易限制类商品（2009）)
VIII.
Yes
No
Unknown
Other Product Information
German WGK / TA-Luft: Please provide
classifications for WGK and TA-Luft
according to VwVwS dated 17/05/99 and
TA-Luft dated 24/07/2002.
Please review the substances listed in
the document “2008 GADSL document”
(http://www.gadsl.org) and indicate
those that exceed the listed thresholds.
European / US Standard CONEG
Antimony (Sb)
Arsenic (As)
Baryum (Ba)
Cadmium (Cd)
Chromium (Cr)
Mercury (Hg)
Lead (Pb)
Selenium (Se)
Cobalt (Co)
Copper (Cu)
Nickel (Ni)
Manganese (Mn)
Vanadium (V)
Zinc (Zn)
WGK:
TA Luft:
Please indicate for WGK the
Annex used for the
classification.(http://www.um
weltbundesamt.de/wgse/index.htm)
Presence
Absence
Exceeding threshold:
Matching
Not matching
Unknown
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Concentration:
Canadian SNAc
Yes
No
Unknown
Chemical Weapons Convention
Yes
No
Unknown
Schedules of Chemicals (Annex)
Singapore Hazardous Substances
Yes
No
Unknown
Control List
Singapore Petroleum and Flammable
Yes
No
Unknown
Materials List
Singapore Explosive Precursors List
Yes
No
Unknown
Malaisian's EHS reference list
Yes
No
Unknown
http://www.doe.gov.my/
Korean Toxic chemicals, Observational Yes
No
Unknown
chemicals, Restricted chemicals or
Prohibited chemicals under the Toxic
Chemicals Control Act.
Due to our commitment to the Green Partnership with SONY, does your product comply with the following
specific requirements of the Sony referential SS-00259 v6:
 cadmium or cadmium
Yes
No
Unknown
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com

compounds < 5 ppm
lead or lead compounds <
100 ppm
Yes
No
Unknown
CERTIFICATION: The information provided is known to be true and accurate as of the date given
on this sheet. This material is completely described by the information provided in the
Composition Information Section (above). If the status of any of the above information changes,
please to inform Arkema (Arkema Inc. or Arkema SA) of the changes in a timely fashion. For any
question you may have concerning this document you may contact:
For Arkema Inc: Carl L. CARLIN, Tel.: +1 215 419 7034 Email: carl.carlin@arkema.com
For Arkema SA: Emeryc VALOT or Catherine CLAMART, Email: arkema.pars-
regulatory-affairs-dsep@arkema.com
Name (print)
Title
Date
E-mail
Address
Signature (Stamp of the company)
GLOSSARY
 Regulation (EC) N° 1272/2008 on classification, labelling and packaging of substances and mixtures
 Regulation (EC) No. 2037/2000 of the European Parliament and of the Council of 29 June 2000 on
substances that deplete the ozone layer.
 Regulation (EC) No. 842/2006 on certain fluorinated greenhouse gases.
 Directive 98/8/EC of the European Parliament and of the Council of 16 February 1998 concerning the
placing of biocidal products on the market.
 Directive 1999/13/EC on the limitation of emissions of volatile organics compounds due to the use of
organic solvents in certain activities and installations.
 Directive 94/62/EC of 20 December 1994 on packaging and packaging waste.
 Directive 2000/76/EC of the European Parliament and of the Council of 4 December 2000 on the
incineration of waste.
 Directive 2000/53/EC of the European Parliament and of the Council of 18 September 2000 on end-of
life vehicles.
 Directive 2002/95/EC of the European Parliament and of the Council of 27 January 2003 on the
restriction of the use of certain hazardous substances in electrical and electronic equipment.
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com





Directive 2005/618/EC Commission Decision of 18 August 2005 amending Directive 2002/95/EC of the
European Parliament and of the Council for the purpose of establishing the maximum concentration values
for certain hazardous substances in electrical and electronic equipment.
Directive 2002/96/EC of the European Parliament and of the Council of 27 January 2003 on waste
electrical and electronic equipment (WEEE).
Swiss law 814.018: Regulation on the incentive tax on Volatile Organic Compouds.
Regulation (EC) No. 850/2004 of the European Parliament and of the Council on persistent organic
pollutants and amending D. 79/117/EC.
Regulation (EC) 1907/2006 list of substances (Annex XIV) « Very High Concern » subjected to
authorization: http://echa.europa.eu/chem_data/authorisation_process/candidate_list_en.asp
For more details of the regulatory texts, refer to the site: http://eur-lex.europa.eu/
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com
Please return the original questionnaire to:
Name
Title
Ginny Richmond________________________________________________ _____
_Purchasing Specialist
Company
Arkema Inc._________________ ______________________________
Address
_900 First Avenue
Address
_King of Prussia, PA 19406_
______________________________________
_______________________
Telephone/ Fax _(610) 205 –7066 ____________________________
E mail
Virginia.Richmond@arkema.com or
arkema.phil-us-purchasing@arkemagroup.com
Arkema Inc.
900 First Avenue
King of Prussia, 19406
Tel.: 610-205-7000
www.arkema-inc.com