Chemical Substances Investigation form

Version 5.1

Miki Pulley Co., Ltd.

（Form-E）

Date:
To:

Certificate of Chemical Substances Non-use in Products【22 substances】

We hereby warrant that the prohibited chemical substances in Table 1 are not contained in the products specified in thefollowing supplied to Miki Pulley Group.
Table 1. Prohibited chemical substances
No1

Chemical substances
Asbestos

Maximum concentration
valuesIntentionally added

Chemical substances
Tri-substiituted organostannic

132

Cadmium(Cd)/Cadmium Compounds

0.01wt%*34

Hexavalent Chromium Compounds(Cr+6)
Lead(Pb)/Lead Compounds

0.1wt%*
0.1wt%*

14155

Mercury(Hg)/Mercury Compounds

0.1wt%*

166Ozone depleting substances (ODS)

Intentionally added

177

Polybrominated Biphenyls(PBBs)

0.1wt%*

188

Polybrominated Diphenyl Ethers(PBDEs)

0.1wt%*

9

Polychlorinated biphenyls (PCBs)

Intentionally added

10

Polychlorinated terphenyls (PCTs)

0.005wt% in material

20

11

Polychlorinated naphthalenes

Intentionally added21

12

Shortchain chlorinated paraffins(C10-C13)

Intentionally added
or 0.1wt% in parts

22

compounds (Includingtributyltin(TBT)&triphenyltin(TPT))

19

Tributhl tin oxide (TBTO)
Dibutyltin (DBT) compounds
Dioctyltin (DOT) compounds(use in contact with skin.)
Perfluorooctane sulfonate(PFOS) and it’s salts
Perfluorooctanoic acid (PFOA),
it’s salts & related substances
Phenol,2-(2H-benzotriazol-2-yl)-4,6bis(1,1-dimethylethyl)
Cobalt dichloride
Hexabromocyclododecane(HBCDD) & it’s isomers
4 specific phthalate esters(DEHP, BBP, DBP, DIBP)

Maximum
concentration values
Intentionally addedor 0.1wt% of tin in parts
0.1wt% of tin in parts
0.1wt% of tin in parts
0.1wt% of tin in parts
Intentionally added
or 0.1wt% in parts<25 ppb of PFOA including its salts<1,000 ppb of PFOA-related substances

Intentionally added,Intentionally added
Intentionally added
or 0.01wt% in parts
0.1wt%** ) wt% in homogeneous materials.

Products for investigation
Product No.

Product Name

Signature

Warranty of non-use(Please enter “✔”markin the applicable column)
Warranty

Remarks

Non-warranty:

Person in charge :Division:

Company Name :04-00107 E09 Ver.5.1

Miki Pulley Co., Ltd.

〔Chemical Substance Investigation Form〕 (22 + 3 substances)(Form-F)

1.【Company information】
Information

Date;
Company Name;
Address;
Division;
Person in charge;

Telephone No.;
FAX No.;2.【Product for investigation】
Maker (Supplier) nameProduct number

Materialunit(pcs, Kg, ,g,m, ㎠ etc.)

Product name
Type (part number)

Process

Investigation
weight3.【Content chemical substance information】(1) Prohibited substancesNo.

123456

Chemical substances
Asbestos
Cadmium(Cd)/Cadmium Compounds
Hexavalent Chromium Compounds (Cr(Ⅵ))

891011

Lead(Pb)/Lead Compounds
Mercury(Hg)/Mercury Compounds
Ozone depleting substances (ODS)
Polybrominated Biphenyls(PBBs)
Polybrominated Diphenyl Ethers(PBDEs)
Polychlorinated biphenyls (PCBs)
Polychlorinated terphenyls (PCTs)
Polychlorinated naphthalenes

12

Shortchain chlorinated paraffins (C10-C13)

13

Tri-substiituted organostannic compounds(Including tributyltin(TBT)&triphenyltin(TPT)

7

14
15

Tributhl tin oxide (TBTO)
Dibutyltin (DBT) compounds
Dioctyltin (DOT) compounds
16(use in contact with skin)
Perfluorooctane sulfonate (PFOS)
17& it’s salts
Perfluorooctanoic acid (PFOA),
18
it’s salts & related substances
Phenol,2-(2H-benzotriazol-2-yl)-4,6-bis(1,119-dimethylethyl)
20 Cobalt dichloride
Hexabromocyclododecane (HBCDD)
21& it’s isomers
Bis(2-ethylhexyl) phthalate (DEHP)
Benzyl butyl phthalate (BBP),
22
Dibutyl phthalate (DBP),
Diisobutyl phthalate (DIBP)*) wt% in homogeneous materials.

Maximum concentration values

Contain (NO or YES)
(Please enter “✔” inthe applicable column)
NOYES

Containedweight (ｇ)or Wt%

Detailed substance information（The substance name, purpose,part name, content rate, etc.）

Contain NO(or YES)
(Please enter “✔” inthe applicable column)
NOYES

Containedweight (ｇ)or Wt%

Detailed substance information（The substance name, purpose,part name, content rate, etc.）

Intentionally added
0.01wt%*0.1wt%*
0.1wt%*
0.1wt%*
Intentionally added
0.1wt%*
0.1wt%*
Intentionally added
0.005wt% in material
Intentionally added
Intentionally added
or 0.1wt% in parts
Intentionally added or0.1wt% of tin in parts
0.1wt% of tin in parts
0.1wt% of tin in parts
0.1wt% of tin in parts
Intentionally added
or 0.1wt% in parts<25 ppb of PFOA including its salts<1,000 ppb of PFOA-related substances

Intentionally added
Intentionally added
Intentionally added
or 0.01wt% in parts
0.1wt%*(2) Controlled substances (Content information only)No.

1
23Substances
Other Phthalates(except DEHP, BBP, DBP, DIBP)
Brominated flame retardants(other than PBBs, PBDEs)
Polyvinyl chloride & it’s mixtures

Maximum concentration
valuesIntentionally added
or 0.1wt% in parts
0.1wt% in the plastics
0.1wt% in the plastics

04-00107 F09 Vr.5.1

Miki Pulley Co., Ltd.

Formats for
the Chemical Substances Investigation
Version 5.1
Published: October 2019
Miki Pulley Co., Ltd.

Miki Pulley Co., Ltd.