"Certificate of Compliance Form - Reduction of Toxics in Packaging - Sample" - Iowa

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Download "Certificate of Compliance Form - Reduction of Toxics in Packaging - Sample" - Iowa

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Rev. 08-06-09
SAMPLE
[COMPANY LETTERHEAD]
Certificate of Compliance
Reduction of Toxics in Packaging
We certify that all packaging and packaging components sold to [Company Name] or its
subsidiaries in the State(s) of [State Name(s)] comply with the requirements of the toxics
in packaging law(s). Specifically:
1) We certify that the regulated metals – lead, mercury, cadmium, and hexavalent
chromium -- were not intentionally added to any package or packaging component
during the manufacturing process.
2) We further certify that the sum of the incidental concentration levels of lead,
mercury, cadmium and hexavalent chromium present in any package or package
component does not exceed 100 parts per million by weight.
3) We will maintain adequate documentation of this certification for inspection upon
request.
COMPANY NAME:________________________________________________
ADDRESS:______________________________________________________
_______________________________________________________________
CERTIFIED BY:
_______________________________
______________________________
(Name)
(Signature)
_______________________________
______________________________
(Title)
(Date)
****Addendum: The State of Iowa (IAC 455D.19) also requires the following certification:
We further certify that no materials used to replace the heavy metals are present in a quantity or
manner that creates a hazard as great or greater than the hazard created by the regulated
metals.
Rev. 08-06-09
SAMPLE
[COMPANY LETTERHEAD]
Certificate of Compliance
Reduction of Toxics in Packaging
We certify that all packaging and packaging components sold to [Company Name] or its
subsidiaries in the State(s) of [State Name(s)] comply with the requirements of the toxics
in packaging law(s). Specifically:
1) We certify that the regulated metals – lead, mercury, cadmium, and hexavalent
chromium -- were not intentionally added to any package or packaging component
during the manufacturing process.
2) We further certify that the sum of the incidental concentration levels of lead,
mercury, cadmium and hexavalent chromium present in any package or package
component does not exceed 100 parts per million by weight.
3) We will maintain adequate documentation of this certification for inspection upon
request.
COMPANY NAME:________________________________________________
ADDRESS:______________________________________________________
_______________________________________________________________
CERTIFIED BY:
_______________________________
______________________________
(Name)
(Signature)
_______________________________
______________________________
(Title)
(Date)
****Addendum: The State of Iowa (IAC 455D.19) also requires the following certification:
We further certify that no materials used to replace the heavy metals are present in a quantity or
manner that creates a hazard as great or greater than the hazard created by the regulated
metals.