Supplier: 

  PT Sulfindo Adiusaha 
Caustic Soda Liquid ( CSL 48%wt ) dan
Product Name:   Hydrochloric Acid ( HCL 32 % wt ) 
Product Reference:    

Signatory Name:   Muhammad Farkhan

Signatory position:  Technical Manager

Date and signature: 

I confirm that the product mentioned above, and each of its components, comply with
the EU regulation on food, especially with regards to the regulation (EC) n°396/2005
on maximum residue levels of pesticides in or on food and feed of plant and animal
origin and its amendments.

Are any agricultural raw materials coming from outside European Union used in making the
product and its components?
YES ☐ NO ☐

If YES,

What are these agricultural raw materials, and where (country of origin) do they come from?
(please replace ‘Component 1’ by its name)
 Component 1: …………………………………………………………………………………
 Component2: ………………………………………………………………………………….
 …………………………………………………………………………………………………..

Which measures have you set up to ensure the absence of ethylene oxide in the product
you deliver to us at each step of its production, including transportation and storage:
 Certificate of analysis
 Analysis control plan
 Supplier audits
 Risk assessment
  Others

Please provide evidence at each of the following steps, for each component of your
product, and for the final product:
Replace “component 1, 2, …” by the components of your product. You may add or delete columns if
necessary.
For each steps of the process, describe the evidence of non-use and absence of ethylene oxide.

Component 1 Component 2 … End product

Raw material /

Production of the
agricultural raw /
material

Transportation of the
/
agricultural raw

Storage of the
agricultural raw /
material

Processing

Transportation

Storage