PRODUCT ASSESSMENT QUESTIONAIRE

Any changes to the information provided in this questionnaire should be reported to the Quality Management
department of Lípidos Santiga, S. A. prior to the following delivery.

SUPPLIER INFORMATION
Name DuPont Nutrition Biosciences ApS
VAT number 16527289
Address Taarnvej 25
Address (cont.)
Place Grindsted ZIP code 7200
Province Country Denmark
Telephone Fax
e-mail
Number 7003
Health Authorization
Activity Food additives
Contact Local sales office
General Manager Martin K. Madsen
Quality Manager Peter V. Madsen

PRODUCT INFORMATION
Product name GRINDSTED® CITREM BC-FS MB
Product reference 103062
Lipsa's product name

Lipsa's product ref.

Product legal name Citric acid ester E472c and Mono-diglyceride of fatty acids E471
Product manufacturer DuPont Nutrition Biosciences ApS
Denmark
Country of production
Attach product sheet and safety data sheet according to Regulation (EC) n. º 1907/2006 of the
European Parliament and of the Council (REACH)

Questionnaire filled in by:

Position in the company:

Date: 28.07.2016

Signature & Stamp

30/01/2014 D-06(7-04)GC.1
 DOCUMENTS RELATED TO THE PRODUCT

Supplier: DuPont Nutrition Biosciences ApS

Manufacturer: DuPont Nutrition Biosciences ApS
Product name. GRINDSTED® CITREM BC-FS MB Product ref. 103062
Lipsa's product name: 0 Lipsa's prod. ref. 0
Indicate for the product and the manufacturer mentioned whether or not you have the following
documentation. If so attach the documentation indicated.

Document Related to Document available?

Product sheet Product Yes 1
Material Safety Data Sheet Product Yes 1
Certificate of packaging suitability for food use Product Yes 1
Kosher certificate Product Yes 1
Halal certificate Manufacturer Yes 1
Cert. HACCP or CCPs Management Chart Manufacturer Yes 1
BRC certificate Manufacturer Yes 1
IFS certificate Manufacturer No -1
ISO / FSSC 22000 certificate Manufacturer No -1
GMP+ certificate Manufacturer No -1
FAMI-QS certificate Manufacturer No -1
ISO 9001 certificate Manufacturer Yes 1
ISO 14000 certificate Manufacturer Yes 1
ISO / OSHAS 18000 certificate Manufacturer Yes 1
SA 8000 certificate Manufacturer No -1
SMETA certificate Manufacturer No -1
Health approval or equivalent Manufacturer No -1
Others (specify):
0
0
0
0
0
0
0
0

Name and position:

Signature and stamp Place and date:

28.07.2016

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 CERTIFICATE OF ALLERGENS
Supplier: DuPont Nutrition Biosciences ApS
Manufacturer: DuPont Nutrition Biosciences ApS
Product name: GRINDSTED® CITREM BC-FS MB Product ref. 103062
Lipsa's product name 0 Lipsa's prod ref 0
Indicate, by choosing an option, the presence or absence of the following ingredients in the product mentioned above,
including the possibility of cross-contamination.
Ingredient Presence / Absence ¿Needs to be labelled? Comments
Cereals containing gluten (1) and
Total absence guaranteed
products thereof
Crustaceans and products thereof Total absence guaranteed

Eggs and products thereof Total absence guaranteed

Fish and products thereof (2) Total absence guaranteed

Peanuts and products thereof Total absence guaranteed

Soybeans and products thereof (3)
Milk and products thereof (including
lactose) (4)
Nuts (5) and products thereof
Possible presence by cross As soya lecithin. Cross contamination not
No detectable.
contamination
Total absence guaranteed
Total absence guaranteed

Celery and products thereof Total absence guaranteed

Mustard and products thereof Total absence guaranteed

Sesame seeds and products thereof Total absence guaranteed

Sulphur dioxide and sulphites (6) Total absence guaranteed

Lupin and products thereof Total absence guaranteed

Molluscs and products thereof Total absence guaranteed

Corn/Maize and products thereof Total absence guaranteed

(1) i.e. wheat (such as spelt and khorasan wheat), rye, barley, oats or their hybridised strains except: (a) wheat-based glucose syrups including dextrose, (b) wheat-based maltodextrins,
(c) glucose syrups based on barley, (d) cereals used for making alcoholic distillates including ethyl alcohol of agricultural origin.
(2) except (a) fish gelatine used as carrier for vitamin or carotenoid preparations; (b) fisg gelatine or Isinglass used as fiing agent in beer and wine.
(3) except (a) fully refined soybean oil and fat; (b) natural mixed tocopherols (E306), natural D-alpha tocopherol, natural D-alpha tocopherol acetate, natural D-alpha tocopherol
succinate from soybean sources; (c) vegetable oils derived phytosterols and phytosterol esters from soybean sources; (d) plant stanol ester produced from vegetable oil sterols from
soybean sources.
(4) except (a) whey used for making alcoholic distillates including ethyl alcohol of agricultural origin; (b) lactitol
(5) Almond (Amygdalus communis L.), Hazelnut (Corylus avellana), Walnut (Juglans regia), Cashew (Anacardium occidentale), Pecan nut (Carya illinoiesis (Wangenh.) K. Koch), Brazil nut
(Bertholletia excelsa), Pistachio nut (Pistacia vera), Macadamia nut and Queensland nut (Macadamia ternifolia), except for nuts used for making alcoholic distillates including ethyl
alcohol of agricultural origin.
(6) at concentrations of more than 10 mg/kg or 10 mg/litre in terms of total SO2 which are to be calculated for products as proposed ready for consumption or as reconstituted
according to the instructions of the manufacturers

Nombre y cargo:

Firma y sello de la empresa Lugar y fecha: 28.07.2016

Cualquier cambio sobre la información facilitada en el presente cuestionario debe ser comunicado al departamento de
Gestión de Calidad de Lípidos Santiga, S. A. antes del siguiente suministro.
 CERTIFICATE OF ORIGIN OF THE PRODUCT

Supplier: DuPont Nutrition Biosciences ApS

Manufacturer: DuPont Nutrition Biosciences ApS
Product name: GRINDSTED® CITREM BC-FS MB Product ref. 103062
Lipsa's product name: 0 Lipsa's prod ref 0
Indicate for each product component mentioned (including possible carriers) its obtaining source, species and
country of origin.

Ingredient Source Species Country of origin

Citric acid ester Vegetable based on palm oil/citric acid Mainly Malaysia and Indonesia
Distilled monoglyceride Vegetable based on palm oil Mainly Malaysia and Indonesia

Name and position:

Signature and stamp: Place & date 28.07.2016

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 CONTROL OF FOREIGN BODIES PRIOR TO PACKAGING

Supplier: DuPont Nutrition Biosciences ApS

Manufacturer: DuPont Nutrition Biosciences ApS
Product name: GRINDSTED® CITREM BC-FS MB Product ref. 103062
Lipsa's product name: 0 Lipsa's prod ref0
Indicate for the product supplied and the manufacturer indicated, the type of foreign material control established before packing. In case of filtration or sieving also indicate
mesh size of the filter or sieve. In case of metal detector indicate the particle size to detect and target sensibility for each metal.
State Comments to the state Type of foreign bodies control Comments to foreign bodies control
Filtration
Metal detector
Mesh size: 200 µm
Particle size to detect:
Target sensitivity for each metal: Fe 4mm non-Fe 6mm SS 5mm
Other comments: see encl. Flow chart

Name and position:

Signature & stamp: Place & date: 28.07.2016

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid Santiga, S. A. prior to the following delivery.
 CERTIFICATE OF NO GMO

In compliance with EC Regulations 1829/2003 and 1830/2003

DuPont Nutrition Biosciences ApS

Certifies for the product

0 / GRINDSTED® CITREM BC-FS MB

produced by:

and supplied to Lípidos Santiga, S.A. that:

• Do not consists of GMO, does not contain GMOs nor is produced from GMOs; including
product carriers.
• The possible accidental or technically unavoidable contamination does not exceed the
maximum limits set (0.9%).

Therefore, the mentioned product does not require a specific labeling as GMO.

Name and position:

Place and date: 28.07.2016

Signature and stamp:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 FOOD USE CERTIFICATE

DuPont Nutrition Biosciences ApS

Certifies for the product

0 / GRINDSTED® CITREM BC-FS MB

produced by: DuPont Nutrition Biosciences ApS

and supplied to Lípidos Santiga, S.A. that:

the mentioned product or any of its ingredients is suitable for food use and that it
complies with all applicable regulations in force in the European Union .

Name and position:

Place and date: 28.07.2016

Signature and stamp:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 CERTIFICATE OF NO IONISING RADIATION

In compliance with Directive 1999/2/CE

DuPont Nutrition Biosciences ApS

Certifies for the product

0 / GRINDSTED® CITREM BC-FS MB

produced by: DuPont Nutrition Biosciences ApS

and supplied to Lípidos Santiga, S.A. that:

• It has not been treated with ionising radiation at any stage of production.

Therefore, the mentioned product does not require a specific labelling as irradiated.

Name and position:

Place and date: 28.07.2016

Signature and stamp:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 CERTIFICATE OF NO BSE / TSE

DuPont Nutrition Biosciences ApS

Certifies for the product

0 / GRINDSTED® CITREM BC-FS MB

produced by: DuPont Nutrition Biosciences ApS

and supplied to Lípidos Santiga, S.A. that:

• The product mentioned or any of its ingredients is not of animal origin.

• That during its production process is not used any raw or auxiliary materials of animal
origin.

• That during the production process there is no risk of accidental or technically

unavoidable contamination with other animal products.

For all of this it is guaranteed that the mentioned product is free from BSE / TSE.

Name and position:

Place and date: 28.07.2016

Signature and stamp:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 CERTIFICADO AUSENCIA MELAMINA

In compliance with Regulation EC 594/2012 which modifies Regulation EC 1881/2006

DuPont Nutrition Biosciences ApS

Certifies for the product

0 / GRINDSTED® CITREM BC-FS MB

produced by: DuPont Nutrition Biosciences ApS

and supplied to Lípidos Santiga, S.A. that:

• The product mentioned or any of its ingredients are free of melamine.

Name and position:

Place and date: 28.07.2016

Signature and stamp:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.
 CONTAMINANTS CONTROL

Supplier: DuPont Nutrition Biosciences ApS

Manufacturer: DuPont Nutrition Biosciences ApS
Product name: GRINDSTED® CITREM BC-FS MB Product ref. 103062
Lipsa's product name: 0 Lipsa's prod ref 0
Indicate for the product supplied and the manufacturer indicated the possible presence or guaranteed absence of the following contaminants:
Maximum level and unit in case of possible presence.
Preventive measures: indicate what measures are applied to ensure that the maximum level is not exceeded.
Analytical control: Indicate the controls carried out and their frequency in order to verify the compliance with the maximum levels set.
Comments: comments to make. In case of the absence guaranteed indicate on what basis is this warranty given.

Maximum
Contaminants Presence / Absence Unit Preventive measures Analytical control Comments
level
Heavy metals
Iron
Copper
Arsenic 3 ppm *Tested on selected products once per year
Lead 2 ppm *
Mercury 1 ppm *
Mycotoxins
Aflatoxin B1 see encl. Statement
Aflatoxins B1+B2+G1+G2
Pesticides * see encl. Monitory Report
PAHs (expressed as BaP) see encl. Statement
Microorganisms
Salmonella abs. In 25g * see encl. Monitory Report
Mouds and yeasts max 100/g *
Lipolytic yeasts

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid Santiga, S. A. prior to the following delivery.
 Nivel
Contaminantes Presencia / Ausencia Ud. Medidas preventivas Controles analíticos Observaciones
máximo
Dioxins & PCBs
Dioxins (PCDDs+PCDFs) see encl. Statement
Dioxins + dlPCBs
dlPCBs
Radioisotopes see encl. Statement
Other contaminants

Nombre y cargo:

Firma y sello de la empresa: Lugar y fecha:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid Santiga, S. A. prior to the following delivery.
 QUALITY GARANTEE CERTIFICATE

DuPont Nutrition Biosciences ApS

Certifies for the product

0 / GRINDSTED® CITREM BC-FS MB

produced by: DuPont Nutrition Biosciences ApS

and supplied to Lípidos Santiga, S.A. that:

1- The supplier is solely responsible for the quality of the supply of products that provides to the customer and
therefore should be sufficient guarantee of compliance with such quality controls that makes their raw materials,
packaging materials and finished products .

2- The products that are delivered to the customer will be inspected upon receipt at the factory in this, entering the
store or in your destination, once identified entry into the factory

3- That accompany each product that the supplier delivered to the customer, will come an certificate of analysis
(COA) product controlled by it to decide whether to accept parameters. All parameters must conform to
specifications, except in cases where the express permission of the client, some parameter might be out of them. In
this case, that fact will be stated clearly in the COA, indicating what the affected parameter and its value accepted by
the customer.

4- The supplier shall always to customer solely responsible for the quality of the product supplied, although in the
manufacturing process any manipulative or outsourced provider intervention.

5- The supplier should always ensure supply in the amounts and terms that the Customer will sue and he has
accepted, always in reference to the Planning information supplied by the customer.

6- The Supplier shall be responsible for the non-conformities with quality specifications agreed or of any breach of
the Health Technical Regulations or any other applicable legal standard that may arise in supplies.

7- The Customer's decision to claim the Supplier for the costs incurred for the first for the repair, adjustment and/or
recovery of production processes and/or services performed reserves, and the products or services concerned
including customer complaints defects caused by the product supplied by arrangement.

Name and position:

Place and date: 28.07.2016

Signature and stamp:

Any changes to the information provided in this questionnaire should be reported to the Quality Management department Lipid
Santiga, S. A. prior to the following delivery.