Material Declaration
<Date of declaration>
Date
<MD ID number> <Supplier (respondent) information>
MD-ID-No. Company name
Division name
Address
<Other information> Contact person
Remark 1 Telephone number
Remark 2 Fax number
Remark 3 E-mail address
SDoC ID-No.
<Product information>
Delivered unit
Product name Product number Product information
Amount Unit
<Material information>
Unit
This materials information shows the amount of hazardous materials contained in 1
Present
If yes,
above threshold
Table Material name Threshold level material mass If yes, information on where it is used
level
Yes/No Mass Unit
Asbestos 0.1%* No
Polychlorinated biphenyls (PCBs) 50 mg/kg No
Chlorofluorocarbons (CFCs) No
Halons No
Other fully halogenated CFCs No
Table A** Carbon tetrachloride No
(materials listed in Ozon depleting 1,1,1-Trichloroethane No
appendix 1 of the substance
no threshold level
Convention)
Hydrochlorofluorocarbons No
Hydrobromofluorocarbons No
Methyl bromide No
Bromochloromethane No
Anti-fouling systems containing organotin compounds 2,500 mg total
No
as a biocide tin/kg
Cadmium and cadmium compounds 100 mg/kg No
Hexavalent chromium and hexavalent chromium
1,000 mg/kg No
compounds
Lead and lead compounds 1,000 mg/kg No
Table B** Mercury and mercury compounds 1,000 mg/kg No
(materials listed in
appendix 2 of the Polybrominated biphenyl (PBBs) 50 mg/kg No
Convention)
Polybrominated dephenyl ethers (PBDEs) 1,000 mg/kg No
Polychloronaphthalenes (Cl >= 3) 50 mg/kg No
Radioactive substances no threshold level No
Certain shortchain chlorinated paraffins 1% No
Perfluorooctane sulfonic acid (PFOS) 10 mg/kg**** No
Annex II***
(Additional
materials)
Brominated Flame Retardant (HBCDD) 100 mg/kg No
*Please refer to footnote 18 on the "Form of Material Declaration" in the IMO Guidelines Resolution MEPC.269(68).
**Hong Kong International Convention for the Safe and Environmentally Sound Recycling of Ships, 2009 ( SR/CONF/45).
***Regulation EU No. 1257/2013 of the European Parliament and of the Council of 20 November 2013 on Ship Recycling and amending Regulation EC No. 1013/2006 and Directive 2009/16/EC
EMSA's Best Practice Guidance on the Inventory of Hazardous Materials, dated 2016-10-28
****Concentrations of PFOS above 10 mg/kg (0.001% by weight) when it occurs in substances or in preparations or concentrations of PFOS in semi-finished products or articles, or parts thereof equal to or above than 0.1% by weight calculated
with reference to the mass of structurally or micro-structurally distinct parts that contain PFOS or for textiles or other coated materials, if the amount of PFOS is equal to or above than 1 μg/m² of the coated material.
Important Notice: The content and specifications of this form may not be changed or amended. Any changes or amendments by others than the author of this form constitute a breach of copyright law.
