PT.

XX

Allergen & Sensitivity Information Form

Product: Fish on Can

Pack Size: XXX

Product Code: XXX

For each product complete the table below:

Column I indicates the allergens that may be found in the product, from addition or cross-contact.
Column II lists the allergen(s) present in the product, produced on the same line, or present in the facility. Please specify using common or usual name.
Column III indicates the allergens present in other products that are run on the same equipment but at a different time.
Column IV indicates whether any allergens are present in your plant.

Please fill in each cell of the table with a YES or NO and, for any column with a YES, include the name of the ingredient.

COLUMN I COLUMN II COLUMN III COLUMN IV

Is this allergen Is this allergen Is the allergen
DO NOT LEAVE EMPTY CELLS in
Column I, III and IV. For all "YES" answers, contained in Specific name of material* manufactured manufactured
please indicate the specific name of the ingredient? component or derivative: or used on same or used in
material in Column II. production line? same plant?
Material Yes or No Material(s) Yes or No Yes or No
ALLERGENS
Milk No - No No
Eggs No Egg Yolk No Yes
Fish Yes Tuna Yes Yes
Crustacea No - No No
Mollusks No - No No
Tree Nuts No - No No
Legumes No - No No
Peanuts No - No No
Soybeans No Soybean Oil Yes Yes
Lupin or its derivatives No - No No
Wheat No - No No
Unrefined Oil No - No No
Grains No - No No
Mustard Seed No Mustard No Yes
Seeds No - No No
Celery or its derivatives No Celery leaf No Yes
SENSITIVITIES /OTHER INFORMATION FOR LABELING PURPOSES
Gluten No No No No
Sulfites
concentrations of more than 10 mg/kg (ppm) or
10 mg/litre (ppm) expressed as SO2. No
Sulfites No Yes
MSG No MSG Yes Yes
HVP No No No No
Colorings No No No No
Caffeine No No No No
Other

Do you have a program in place to eliminate cross contact of allergenic with non-allergenic materials? YES ✘ NO

Please describe: Attached IK.SS.17

Name/Title/ Phone #: Tunjiah/ Quality & Technology Jr. Manager/ +62-343-851361

Date: July, 13th 2018

592410685.xls Effective 12/3/2015 Approved: Winston Chance, Director Quality Assurance