Raw Material Supplier Form Section 1 General Information Product Name: Supplier Product No.: Country of Origin: Grade: (delete the irrelevant) technical, cosmetic, food, pharma, NA Please provide Safety Data Sheet for United States and European Union. Supplier Company Information Name Address Phone Website ISO Certifications (List all): Trade Associations: List all (global) to which you hold a membership Participate in Yes/ No Responsible Care® or similar program? Section 2 Contact Information Commercial Contact Manufacturer Company Information Name Address Phone Website ISO Certifications (List all): Trade Associations: List all (global) to which you hold a membership Participate in Yes/ No Responsible Care® or similar program? Technical Contact REACH Contact Name Address Phone Email Purchasing Contact Regulatory Contact Name Address Phone Email The below signature certifies that all the information supplied in this form is current, complete, and accurate. The supplier understands that Milliken & Company is relying on Supplier’s certification to ensure Milliken & Company’s compliance with applicable global legal requirements and regulations. Name: Phone: Email: Signature: Date: Section 3 Environmental Compliance 1* Regulated Components CAS # Max Wt % 2* 3* 4* 5* 6* A response for each section is required. CAA HAP CAA VOC State TAP CWA CERCLA RQ (lbs) SARA 302 EHS 7* SARA 313 1 2 3 4 5 6 7 8 9 *see Appendix A for explanations Answer at least one of the below questions with regards to Volatile Organic Compounds (VOCs): 1) Total VOC’s by EPA method 24/24A (%):__________________ 2) Total VOC’s estimated based on product composition (%): ______________________ Section 4 Metals Analysis 1) Be sure to provide correct units for values. 2) Detection limit – mark value with *. 3) Not present – mark with NP for those metals that are not intentionally added or not expected to be present. 4) Please provide data on hand. No new testing is required at this time. Al Ba B Cr VI Fe Mg Pb Te Sn Metal Aluminum Barium Boron Chromium VI Iron Magnesium Lead Tellurium Tin organic Rev #: 5 Max Value Sb Be Cd Co LI Mn Se Tl Zn Metal Antimony Beryllium Cadmium Cobalt Lithium Manganese Selenium Thallium Zinc Max Value Rev. Date: April 26, 2013 As Bi Cr III Cu Hg Ni Ag Sn Metal Arsenic Bismuth Chromium III Copper Mercury Nickel Silver Tin Max Value Page 2 of 9 Section 5 General Hazard and Compliance Information: United States Regulations Is product hazardous under the OSHA HAZCOM 2012 standard? Is the product a SARA 311/312 Hazard? Is the product DOT regulated? No Yes ☐ ☐ ☐ Please delete the hazards which do not apply to this product: acute/chronic/fire/pressure/reactive Proper shipping name: Substance: Is the product considered a RCRA Hazardous Waste? Is the product or any components regulated by California Proposition 65 (Prop 65)? European Regulations Is the product classified according to DSD (67/548/EEC), DPD (1999/45/EC),and CLP (1272/2008)? Is this product classified under German Water Hazard (WGK)? Is the product compliant to CONEG? ☐ ☐ info ☐ info ☐ ☐ ☐ Is product EU Council Reg. EC No 2037/2000 compliant? Is the product compliant to Directive 2011/65/EU on the restriction of the use of certain hazardous substances in electrical and electronic equipment (RoHS) and is the product compliant to Directive 2002/96/EC on waste electrical and electronic equipment (WEEE)? Is the product compliant to Directive 94/62/EC on packaging and packaging waste? Is the product compliant to Directive 2000/53/EC on end-of life vehicles? Is the product compliant to Safety of Toys EN 71 part 3 and part 9? Is the product compliant to the Cosmetics Directive 76/768/EC and its subsequent amendments? Does your product have any approvals or certifications for US or EU Pharmacopoeia? Other International Regulations Is this product classified under UNGHS regulations? Rev #: 5 ☐ Details Listed/characteristic waste code(s): info ☐ ☐ If yes, please specify. info ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ info Please specify Monographs ☐ ☐ If yes, please specify. Rev. Date: April 26, 2013 Page 3 of 9 Other International Regulations Is this regulated for transportation under IATA or IMDG? No Yes Details ☐ ☐ If yes, please specify. Please provide the ratings for the following categories according to the HMIS Hazard Rating system: Health Flammability Reactivity Flashpoint: Recommended Personal Protective Equipment: Section 6 Toxicological Data (as available) Data Species Test Method Ingestion LD50 (mg/Kg) Inhalation LC50 (mg/Kg) Respiratory Sensitizer Eye Irritation / Damage Dermal LD50 (mg/Kg) Skin Corrosion / Irritation Skin Sensitizer Fish Tox LC50 (mg/L) Daphnia LC50 (mg/L) Mutagenicity Carcinogenicity Reproductive Toxicity Subacute/Subchronic Toxicity Biodegradability (aerobic & anaerobic) Octanol Water Partition Coefficient Kow Additional Data Is the product tested on animals? ☐Yes Rev #: 5 ☐No Rev. Date: April 26, 2013 Page 4 of 9 Section 7 International Chemical Substances Approvals (include impurities or by-products) * EC No.: _________ 1) Is this product or any component subject to regulation by US EPA such as SNUR, PAIR, etc? ☒Yes ☐No If yes, please explain. Section 8 Product Origin and Allergens Does this product contain or is derived from any of the below? Y/N Substance Max Amt CAS # Genetically Modified Organisms Synthetic origin? Mineral origin? Specify Animal Origin? Specify Contains BSE/TSE? Plant Origin? Specify Allergens: Peanuts Soy Beans Milk Eggs Fish Crustaceans Tree Nuts Wheat Cereals w/gluten Celery Sesame Seed Natural Latex Other- specify Is product Kosher certified? ☐Yes Is product Halal certified? ☐Yes Rev #: 5 ☐No ☐No Rev. Date: April 26, 2013 Page 5 of 9 Taiwan - ECN New Zealand – NZIoC China – IECSC Philippines – PICCS Korea – ECL Japan – ENCS Australia – AICS EU – ELINCS* EU- EINECS* Canada- DSL Wt% Canada- NDSL CAS RN US - TSCA Component Section 9 REACh Status n y Pre-registered ☐ ☐ Registered ☐ ☐ If yes, Reg No.: Exempted ☐ ☐ Reason: Uses Supported ☐ ☐ Comments If no, planned date: Use Description Substances of Very High Concern (SVHC) reference link: Candidate List ☐ Our product defined above does not contain any of the chemicals listed in the Candidate List (last update prior to completion date of this form) of Substances of Very High Concern for Authorization stated in the REACH Regulation (1907/2006/EC), in a concentration above 0.1%. ☐ As revisions are made to the Candidate List which effect a change in the status of the subject product supplied to Milliken & Company by our company, we will communicate the change in status within 30 days. Please complete the table below for any components that are on the List of Substances of Very High Concern for Authorization, last update prior to completion date of this form. Add lines as needed. Name of Substance CAS No. EC No. Contents % Classification, Labeling, and Packaging (CLP) Has the material CLP classification and labeling been notified in accordance with Article 39 of Classification, labeling, and packaging of substances of mixtures regulation 1272/2008? ☐Yes ☐No If no, please state reason: If yes, what is the hazard classification? Please mark with an “X” in the appropriate box(es) below if any of the substances are classified as carcinogenic, mutagenic, or reprotoxic in accordance with 67/548/EEC and CLP Regulation No. 1272/2008 and their subsequent amendments. Category 1 Category 2 Category 3 Yes Rev #: 5 Rev. Date: April 26, 2013 Page 6 of 9 Section 10 Substances of Concern Does your product contain any of these substances of concern? Please explain any “yes” answers below the table. Y/N Max Amt Chemical name CAS # Algaecide/Biocide Alkyl phenols (straight chain) and their ethoxylates Aromatic amines Aromatic hydrocarbons Asbestos Azo colorants/compounds Bisphenol A Brominated flame retardants (other than PBB/PBDE) Butylated Hydroxytoluene (BHT) Canadian Challenge Substances Defoamers Diaryl Pigments 1,4-Dioxane Dioxins/Furans (e.g. brominated/chlorinated) Epoxy derivatives (e.g. BADGE, BFDGE, NOGE) Ethylene Oxide Fluorochemicals Formaldehyde or potential formaldehyde releasers/donors Halogens and their compounds (e.g. brominated/chlorinated) Mono- and Diethylene series glycol ethers Naphthalene Nonyl phenol and nonyl phenol ethoxylates Organotin Compounds (Tributyl tin or Triphenyl tin compounds) Ortho Phenyl Phenol Ozone Depleting Substances, Class I Ozone Depleting Substances, Class II Paradiclhorbenzene (PDCB) Perfluorooctanoic Acid (PFOA) Phthalates Polybrominated biphenyls (PBB) Poly brominated diphenyl ethers/oxides (PBDE/PBDO) Polybrominated Flame Retardants (PBFR) Polychlorinated biphenyls (PCB) Polychlorinated terphenyls (PCT) Polychlorinated naphthalenes (PCN) - (>3 Cl atoms) Polyvinyl chloride (PVC)/ PVC Blends Radioactive Substances Shortchain Chlorinated paraffins (C10-13; Cl>=50 wt%) Sodium nitrite and/or added secondary Rev #: 5 Rev. Date: April 26, 2013 Page 7 of 9 Y/N Max Amt Chemical name CAS # amines, nitrosating agents or preformed nitrosamines e.g. surfactant/preservative and surfactant/nitrite combinations that may lead to the formation of nitrosamines Surface Active Agent Triclosan Tris (nonylphenyl) Phosphite Please explain “yes” answers: Section 11 Food Contact Compliance in component section below.) (If product is NOT food contact compliant, put Not Applicable Please supply applicable reference numbers, conditions, exemptions, restrictions and/or specifications below the table in the appropriate area. Be sure to include all substances with a Specific Migration Limit (SML). (Add lines to table as needed) Please put an “X” in the appropriate box if the component complies with: Compliance with BfR- list paragraphs (EC) 2023/2006 (GMP) (EC) No. 1935/2004 Dual Use Additive? South America (MERCOSUR) Japan (JHOSPA) China (GB9685:2008) EU No 10/2011 (Plastics Implementing Measure, PIM) United States (FDA) Component 1) US (FDA) 2) EU No. 10/2011 (PIM) 3) China (GB9685:2008) 4) Japan (JHOSPA) 5) South America (MERCOSUR) Rev #: 5 Rev. Date: April 26, 2013 Page 8 of 9 Raw Material Supplier Form Appendix A Explanation and instructions for Environmental Compliance section. *1- CAA HAP - Hazardous Air Pollutant, including all chemicals listed in the 1990 Clean Air Act (Note: No de minimus level for HAPs). Please put “Y” for Yes or “N” for No. *2- CAA VOC -VOC as defined by 40 CFR 51.100. Please put “Y” for Yes or “N” for No. *3- State TAP - South Carolina Standard 8 TAP. Please put SC, if this applies. *4- CWA - Priority Pollutants as specified by 40 CFR 401.15. Please put “Y” for Yes or “N” for No. *5- CERCLA RQ (lbs) - In this column, please enter the CERCLA Reportable Quantity (RQ) or Section 304 EHS RQ for the component, whichever is less. If the component does not have a Reportable Quantity under CERCLA or Section 304, please enter “None” rather than leave the column blank. CERCLA RQs can be found in 40 CFR 302.4. Section 304 RQs can be found in 40 CFR 355 Subpart D. Both can be found in the EPA’s List of Lists. (Be aware that the List of Lists is current only to 2006.) *6- SARA 302 EHS - SARA Extremely Hazardous Substance. Section 302. Please put “Y” for Yes or “N” for No. *7- SARA 313 - SARA Toxic Chemical Section 313 (40 CFR 372 & amendments published in the Federal Register). Please put “Y” for Yes or “N” for No. CHANGE LOG Date 9/2/11 3/1/12 Rev # 1 2 Initials ALR ALR 4/24/12 2/21/13 3 4 ALR ALR/ WSC 4/26/13 5 Description of Change logo Added statement under SVHC for supplier pro-active communication; Added flashpoint; added link to CONEG facts sheet; Added metals for EU; Added web link for WEEE; Added ELV Added ISO certs, RC participation, Trade associations; reformatted CLP CMR Added request for units in Sec. 4, removed VOCs line items in Sec.10, added instruction for metals, removed trade organization in Sec 1. Rearranged Section 5 for better clarification. Added ISO certs, RC participation & Trade associations which had been inadvertently deleted and rearranged to better utilize space.