ANNUAL NOTIFICATION
FORM
Sodium Fluoroacetate (1080)
Annual Sodium Fluoroacetate (1080) Holding
Notification
Under regulation 53 of the Hazardous Substances (Classes 6, 8 and 9 Controls) Regulations 2001 and regulation
17 of the Hazardous Substances (Exempt Laboratories) Regulations 2001.
Send by post to: Environmental Protection Authority, Private Bag 63002, Waterloo Quay, Wellington 6140
OR email to: 1080Notifications@epa.govt.nz with Notification of Holding Sodium Fluoroacetate (1080) in the subject line.
Completing this notification form
This form is for the annual notification of transactions for the period 1 January to 31 December of sodium
fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8, approval number HSR002771), with
the exception of the 2015 calendar year which covers the period 12 March to 31 December 2015.
The form must be submitted by 31 March of the following year.
Formulated substances containing sodium fluoroacetate are not required to be notified to the EPA. If you need
help to complete the notification form, phone the Inbound Customer Services Administrator (0800 429 7827), or
email 1080notifications@epa.govt.nz
The notification form may be completed manually or electronically.
OFFICE USE ONLY
Application code
Date received
EPA Contact
www.epa.govt.nz
2
Official information
Information you provide in this form is subject to potential disclosure under the Official Information
Act 1982 (OIA). Commercially sensitive information must be marked as such and may be withheld in the event of
an OIA request, if permitted by the OIA. Further information on the OIA is available at
www.ombudsmen.parliament.nz.
Privacy
You have the right to access and correct any personal information in connection with your notification under the
Privacy Act 1993.
December 2015
3
1. Period of notification
2015 Period
From 12 March 2015
to
31 December 2015
2. Notifier details
Name of Company/Laboratory:
one person/entity only
Physical address of Company/Laboratory
where the 1080 is being held:
include postcode
Postal address:
if different from physical address
Company/Laboratory email address:
If notifying for a laboratory - is the
laboratory exempt under the Hazardous
Substances (Exempt Laboratories)
Regulations 2001?
Yes/ No/ Not
applicable
Company/Laboratory phone:
(0_)
(0__)
(0_)
work
mobile
fax
(0_)
(0__)
(0_)
work
mobile
fax
2.1. Contact person details
Contact name of the person in charge of
the manufacturing facility or the laboratory
manager
Position/Job title:
Email address:
Phone:
December 2015
4
3. Purpose for obtaining or manufacturing the sodium
fluoroacetate (1080)
This section is for the notification of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8,
approval number HSR002771). Formulated substances containing sodium fluoroacetate are not required to be notified to the EPA.
Purpose:
4. Information on sodium fluoroacetate (1080) present on site
This section is for the notification of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8,
approval number HSR002771) held during the reporting period. Formulated substances containing sodium fluoroacetate are not
required to be notified to the EPA.
Quantity of product:
Quantity held over the period of
this notification. Please specify
units and enter net weight only.
5. Information on sodium fluoroacetate (1080) manufactured on
site
This section is for the notification of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8,
approval number HSR002771) manufactured during the reporting period. Formulated substances containing sodium fluoroacetate are
not required to be notified to the EPA.
Quantity of product:
Quantity manufactured over the
period of this notification. Please
specify units and enter net weight
only.
December 2015
5
6. Information on sodium fluoroacetate (1080) obtained from
another supplier
This section is for the notification of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8,
approval number HSR002771) obtained from a tanother party during the reporting period. Formulated substances containing sodium
fluoroacetate are not required to be notified to the EPA.
Source of product:
Manufacturer/supplier name and address
December 2015
Quantity of product:
Quantity obtained over the period of this notification.
Please specify units and enter net weight only.
6
7. Information on transfer of sodium fluoroacetate (1080)
This section is for the notification of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8,
approval number HSR002771) transferred to another party during the reporting period. Formulated substances containing sodium
fluoroacetate are not required to be notified to the EPA.
Quantity of transaction
Please specify units and
enter net weight only.
Name of site
1080 was
transferred to:
December 2015
Physical address
of site transferred
to:
Postal address of
site transferred
to: :
include postcode
if different from
physical address
Transfer site
email address:
Identity and position
of responsible person
at the transfer site
Date of transfer
Reason for transfer
7
8. Information on disposal of sodium fluoroacetate (1080)
This form is only for the notification of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-748, approval number HSR002771) disposed of during the reporting period . Formulated substances containing sodium fluoroacetate are
not required to be notified to the EPA.
Date of disposal
Quantity of product:
Method of disposal:
Quantity held as at the date of this notification.
Please specify units and enter net weight only.
9. Signature of person in charge of the manufacturing facility or
the laboratory manager

To the best of my knowledge, the information contained in all sections of this form is complete and correct.

I understand that information presented to the EPA is potentially subject to disclosure under the OIA.

I agree that the EPA may collect/verify information relevant to this notification from/with other parties.

I have identified any commercially sensitive information on the form.
Name:
Position:
Signature:
Date:
December 2015
8
December 2015