Certificate of compliance (EN 10204 - 2.

1)

Customer Name DO/Inv No. PO No. Date

FICO INDO REKAYASA, PT MDO-027 256 PO/XII/23/FC-3385 04/01/2024

With reference to the above DO and Invoice number, we certify that the material of the following item is manufactured in
accordance with the regulation of:

1) FDA CFR 21, 177.2600

Item Description : MINOX DN65/2.5" DIN GASKET <EPDM>

Rubber Material : EPDM

Lot No. :

Remark:
We hereby certify that the material for the above mentioned part is Phthalate Free and free of Animal
Derived Ingredients.
The product meets the requirement of the standard concerned and of the order.

QC Manager
Note:
This is a computer generated document, no signature is require.