Request for import certificate




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REQUEST FOR IMPORT CERTIFICATE



Send by post to: Environmental Protection Authority, Private Bag 63002, Waterloo Quay, Wellington 6140

OR email to: 1080Notifications@epa.govt.nz with Request for Import Certificate for Sodium Fluoroacetate (1080) in the subject line.

Import of Sodium Fluoroacetate (1080)

Under regulation 54 of the Hazardous Substances (Classes 6, 8 and 9 Controls) Regulations 2001 and regulation 19 of the Hazardous Substances (Exempt Laboratories) Regulations 2001.








Completing this form

This form is only for the import of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8, approval number HSR002771). Formulated substances containing sodium fluoroacetate do not require an import certificate. If you need help to complete this request for an import certificate, phone the Inbound Customer Services Administrator (0800 429 7827), or email 1080notifications@epa.govt.nz.

The request for an import certificate form may be completed manually or electronically.



OFFICE USE ONLY




Application code

     

Date received

     

EPA contact

     






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 this request for an import certificate under the Privacy Act 1993.

Importer details



Name of Company/Laboratory:
one person/entity only

     

Physical address of Company/Laboratory:
include postcode

     

Postal address:
if different from physical address

     

Company/Laboratory email address:

     

Company/Laboratory Phone:



(0_)
work

(0__)
mobile

(0_)
fax

Name of person collecting shipment:


     








1.1.Contact person details




Contact name:
of person in charge/laboratory manager

     



Position/Job title:



     



Email address:



     



Phone:



(0_)
work

(0__)
mobile

(0_)
fax




  1. Information on sodium fluoroacetate (1080)

This form is only for the import of any quantity of sodium fluoroacetate (Chemical Abstracts Service (CAS) registry number 62-74-8, approval number HSR002771). Formulated substances containing sodium fluoroacetate do not require an import certificate.



Name of product (trade name):

     


Source of product:

Manufacturer/supplier name and address

     

Quantity of product:

Quantity in this consignment. Please specify units and enter net weight only.

     




Signature of laboratory manager/person importing




  • 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 request for an import certificate from/with other parties.



Name:

     

Position:

     

Signature:

     

Date:

     




www.epa.govt.nz




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