END-USER DECLARATION (EUD) Please fill-out this form legibly and completely. "URCHASE DETAILS | ProductName | CASNo "Pack Size Total Quantity Invoice no. / Delivery Receipt | | - | No. Hydrochloric | 4 ‘cd (HCI) DECLARATION 1,___NECIL G. BOHOLANO being Engineer II - Material Testing Unit Head (Full Name) (Designation in the Company) ‘on behalf of Department of Public Works and Highways - Camiguin District Engineering Office / Poblacion Mambajao, Camiguin (Complete Name and Address of Company / Institution) declare that the above controlled chemical will be used as_ chemical reagent for Chemical Analysis of Cement specifically in the testing of Insoluble Residue, Sulfur Trioxide, ; (Specify n detail the intended use of the chemical) _and Magnesium Oxide Further declaring that aforecited controlled chemical will not be used for the manufacture of illicit drug/s or diverted for illegal purposes. Further affirm that the company is amenable in the conduct of inspection/verification of aforementioned by PDEA Regulatory Compliance Officers at any reasonable business hours. DETAILS OF BUYER'S IDENTIFICATION (Attach photocopy of presented identification with current photo) Drivers License No: NIA Issued at NIA valid ntit__N/A Company ID No: _12MO077 Valid Until_ N/A. Contact Nos (tel fax /email)__ 09356813358 / necilyoholano76@gmail.com io ~ Dithicd Engineer | 34-23, ed name, Signature, Designation/ Date) | EUD Reference No: To be filled by Supplier Received by: On:tatoastnsrie 29, 1976 ye002900841 e11y 8. Bohol oonsag7eai7