(Form 5)

Carrier Japan_Declaration of Use/Non-Use of Specified Chemical Substances240401Rev.

Response date(YYYY/MM/DD)

Preparer

Responsible party

Company nameCompany nameResponsible party

Job title/section

Job title/section

signature

Name

NamePhone(Please be sure to fill in even if Responsible party is the same as Preparer.)

E-mail(If submitting on paper, please sign Responsible party.)

We certify that the following responses are correct.
Covered item
Part name(*1) If there is a request for analysis results, please attach a separate file (check "Analysis").
Manufacturer's model No. Mass (g) Analysis(*1)
Manufacturer

Drawing No.

Response on Contained or Non of specified chemical substances
1. Rank A: Prohibited substances (category)
Prohibited substances (category)

Non

Contained or Non
Contained Contained
exempted use above threshold

A01
A02
A03
A04
A05
A06
A07
A08
A09
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
A20
A21
A22
A23
A24
A25
A26
A27
A28
A29
A30
A31
A32
A33
A34
A35

Asbestos
Certain azocolourants and azodyes (only those that may release certain amines)
Cadmium and cadmium compounds
Hexavalent chromium compounds
Lead and lead compounds
Mercury and mercury compounds
Ozone depleting substances (CFCs, HCFCs, HBFCs, carbon tetrachloride, etc.)
Polybrominated biphenyls (PBBs)
Polybrominated diphenylethers (PBDEs)
Polychlorinated biphenyls (PCBs)
Polychlorinated naphthalenes (more than 1 chlorine atoms)
Radioactive substances
Certain short chain chlorinated paraffins (with a carbon chain length of between 10 and 13)
Tributyl tin (TBT) and triphenyl tin (TPT)
Tributyl tin oxide (TBTO)
2-(2H-1,2,3-benzotriazol-2-il)-4,6-di-tert-butylphenol (UV-320)
Perfluoro (octane-1-sulfonic acid) (also known as PFOS) or its salt and PFOS-related compouds
Perfluoro (octane-1-sulfonyl) fluoride (also known as PFOSF)
Polychlorinated terphenyls (PCTs)
Tri-substituted organostannic compounds (excluding A14 and A15)
Dimethyl fumarate (DMF)
Dioctyltin compounds (DOT)
Dibutyltin compounds (DBT)
Hexabromocyclododecane (HBCD)
Polycyclic aromatic hydrocarbons (PAHs) (BaP,BeP,BaA,CHR,BbFA,BjFA,BkFA,DBAhA)
Bis (2-ethylhexyl) phthalate (DEHP)
Dibutyl phthalate (DBP)
Butyl benzyl phthalate (BBP)
Diisobutyl Phthalate (DIBP)
Phenol, isopropylated phosphate (PIP (3:1))
Perfluorooctanoic acid (PFOA), its salts and related compounds
C9-C14 Perfluorocarboxylic acids (C9-C14 PFCAs), their salts and related substances
Perfluorohexane sulfonic acid (PFHxS), its salts and related substances
Dechlorane Plus
UV-328

2. Rank B: Managed substances (category)Managed substance category
B01
B02
B03
B04
B05
B06
B07
B08
B09
B10
B13
B14

Non Contained

Contained Unknown

Brominated flame retardants, other than PBBs (A08) and PBDEs (A09)
Nickel and its compounds (only parts in contact with human bodies)
Certain phthalates, other than DEHP(A52),DBP(A53),BBP(A54),DIBP(A55) and designated phthalates(B07)
Perfluorocarbons (PFCs)
Hydrofluorocarbons (HFCs)
Sulfur hexafluoride (SF6)
Substances of Very High Concern (SVHC) under the EU REACH Regulation (*2)
The U.S. TSCA PBT Rules (5 substances) (excluding DecaBDE (A09) and PIP (3:1) (A30))
Tetrabromobisphenol A (TBBPA)
Medium-chain chlorinated paraffins (MCCP)PFAS (Per- and polyfluoroalkyl substances)
C15-C21 perfluorocarboxylic acids (C15-C21 PFCAs), their salts and related substances(*2) In case of No.B07 "Contained", please be sure to fill in chemSHERPA.

[Remarks] For the substances No.A03 to A06, if they are "Contained (exempted use)", please enter the part where it is used and the exempted use number.(1800 bytes or less)4
Ｂｙｔｅ

3. Confirmation of Red phosphorus (used as a flame retardant for resins)
Red phosphorus is not a prohibited substance under environmental laws and regulations, but there are concerns about the effects on electrical components
when red phosphorus hydrolyzes, so we prohibit its use in principle for safety management. If you have no choice but to use red phosphorus, please fill in it.

SubstanceZ01

Red phosphorus (used as a flame retardant for resins)

Non Contained

Contained