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(Insert Company Letterhead)

*** By signing this document you are representing that you are authorized to make claims
on behalf of your company in regards to Proposition 65, and that such claims can be relied
upon ***

Company Name:

DECLARATION OF Prop 65 COMPLIANCE

Prop65 Compliance Statement

The part(s)/product(s) in the tables below list which do and which do not contain substances described in the
most current revision of the California’s Safe Drinking Water and Toxic Enforcement Act of 1986 (Proposition
65). The latest material list can be viewed here.

Compliant Prop 65 Parts List

Part Number(s) Description

Non-Compliant Prop 65 Parts List

CAS Number
Part Number(s) Description Substance Name
(If Applicable)

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Name: Signed:

Title: Date:

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