1、Self-declaration formPolymerics materialsSpec. nr: Date: Version nrIOS-MAT-00102013-05-10AA-10911-11 IKEA of Sweden AB 2013 Page 1Self declaration for polymerics including plastics, silicone and rubber/ elastomers/ latex, according to IOS-MAT-0010针对 IOS-MAT-0010 聚合物包括塑料、硅胶、和橡胶/弹性体/ 乳胶体材料的自我声明This fo
2、rm shall be used to certify compliance with requirements according to specification IOS-MAT-0010(AA-10911-11). This form-or an equivalent form with the same information- is to be signed by the final formulator(material producer) of the final polymeric material, i.e. the moulder or extruder(or the su
3、pplier of granules if they are pre-coloured and the moulder/ extruder does not add any additives when forming the plastic component ). This can be either the IKEA supplier or a sub-supplier(or a sub-sub-supplier, etc).此文件是针对 IOS-MAT-0010(AA-10911-11)的符合性声明。此文件或具备同等信息的声明文件由聚合物完结材料的最终成型方（材料生产商）签署，即成型或
4、挤出供应商（或进行预着色的粒子供应商，如果成型或挤出方在制作塑料部件时未添加任何化学助剂）。该签署人可以是宜家供应商或其下级供应商（或下-下级供应商，等）。The self declaration shall be in English addition of information in local language is voluntary.自我声明必须是英文的，以当地语言陈述的附加信息仅作参考。Supporting documents, verifying fulfillment of the requirements, shall be listed inTable 4, such a
5、s: Test reports, Self declarations or certificates from sub-suppliers of raw material and chemicals used to make the polymeric material.支持文件，即证实可以满足要求的文件，须列在表 4 中，比如： 测试报告 来自于生产该聚合材料所需的原材料和化学产品的下级供应商的自我声明或证书。Table 1. List of polymeric material materials表 1. 聚合物材料清单Material identification(trade name,
6、 article code, quality and/or other identification) 1材料识别信息（商品名，产品编码，质量和/ 或其它识别信息） 1Material description (type of material such as material base content, physical characteristics, colour ect)材料描述（材料类别例如材料基本内容，物理特性，颜色等）Contains only virgin polymeric material仅含未经使用的聚合材料Contains external recycled polym
7、eric(state range of percentage of external recycled material)含有来自于外部的回收聚合材料（具体说明所含外部回收材料的比例）Self-declaration formPolymerics materialsSpec. nr: Date: Version nrIOS-MAT-00102013-05-10AA-10911-11 IKEA of Sweden AB 2013 Page 21 When referring to chemical substances that are included in lists established
8、 by government authorities, this SD applies to chemical substances that are included in such list at the time of signing. 对引用来自政府制定的法规和标准里面的化学物质清单时，此声明适用于签署时清单里的物质。Table 2. Confirmation of fulfillment of chemical requirements表格 2，对化学品要求的确认Requirements Type of polymeric material Fulfils NotSee IOS-MA
9、T-0010 for specific applicableinformation on each requirement 聚合材料的类型 满足 不适用要求：参见 IOS-MAT-0010 各具体要求Authorisation substances according All to EU REACH Annex XIV1 所有授权物质（依据欧盟 REACH 法规附录 XIV） Cadmium and its compounds All 镉及镉的化合物 所有CMR substances 1A or1B1 All 1A 或 1B 类 CMR 物质 所有Hazardous waste Materia
10、l that contains any 有害废料 proportion of recycled material材料中包含任何比例的回收材料Lead and its compounds All 铅及铅的化合物 所有Other SVHC1 All 其他 SVHC 所有PBT-substances and vPvB-substances1 All PBT-物质（持久的，生物累积的和有毒的物质） 所有和 vPvB-物质（高持久的和高生物累积的物质） 1Azodyes that may release Materials where colouring carcinogenic arylamines
11、agents have been added可能释放致癌芳香胺的偶氮染料 材料中添加有着色粒子Bisphenol A Plastic material 双酚 A 塑料材料CFCs(Chlorofluorocarbons) and Foamed plastic HCFCs(hydrochloro-fluorocarbons) 泡沫塑料 CFCs（氟氯烷烃）和 HCFCs（氢氯氟烷烃）Heavy metal(extractable) All 重金属（可析出） 所有Self-declaration formPolymerics materialsSpec. nr: Date: Version nrI
12、OS-MAT-00102013-05-10AA-10911-11 IKEA of Sweden AB 2013 Page 3Table 2. Confirmation of fulfillment of chemical requirements表格 2，对化学品要求的确认Requirements Type of polymeric material Fulfils NotSee IOS-MAT-0010 for specific applicableinformation on each requirement 聚合材料的类型 满足 不适用要求：参见 IOS-MAT-0010 各具体要求He
13、xavalent chromium(Cr-VI) All compounds 所有六价铬化合物(Cr-VI)Lindane Materials consisting wholly or 林丹 partly of natural latex/rubber 材料由全部或部分天然乳胶/橡胶组成 Mercury(Hg) and its compounds All 汞(Hg)及汞的化合物 所有 Organotin compounds All 有机锡化合物 所有 Pentachlorophenol(PCP) including Materials consisting wholly or salts an
14、d esters of PCP partly of natural latex/rubber 五氯苯酚 (PCP) 包括 PCP 的盐类和酯类 材料由全部或部分天然乳胶/橡胶组成 Phthalates All 邻苯二甲酸酯 所有Polycyclic aromatic hydrocarbons All except rubber components that (PAH) contain carbon black, that are with-稠环芳烃(PAH) out skin-contact during usage, andwhere tensile and abrasion wearpr
15、operties are needed所有，除了橡胶组件如含有碳黑，非皮肤接触用途，需具有可拉伸及磨损特性Polycyclic aromatic hydrocarbons Rubber components that (PAH) （exception: higher CLVs） contain carbon black, that are with-稠环芳烃(PAH) (例外：高 CLV 物质) out skin-contact during usage, andwhere tensile and abrasion wearproperties are needed橡胶组件如含有碳黑，非皮肤接
16、触用途，需具有可拉伸及磨损特性Polyvinyl-chloride(PVC) All 聚氯乙烯（PVC） 所有Self-declaration formPolymerics materialsSpec. nr: Date: Version nrIOS-MAT-00102013-05-10AA-10911-11 IKEA of Sweden AB 2013 Page 4Note:”Not applicable” shall only be ticked if the material being declared is not in the scope of the requirement ac
17、cording to IOS-MAT-0010.注：“不适用”仅在被声明材料不属于 IOS-MAT-0010 要求范围之内时可选。2 Documentation as required in the approval from IKEA shall be attached to this SD.作为宜家许可的文件需要附在此声明内。3 “Fulfils(no use)”= No use of any flame retardant or only use of melamine, chalk, graphite, kaolin or modacrylic fibre.“满足（未使用）“=没有使用
18、任何阻燃剂或仅使用了三聚氰胺，碳酸钙，石墨，高岭土或改性聚丙烯腈纤维。4 Allowed to be used before datestamp 1402 for final IKEA sales article包装周数章为 1402 周之前的宜家产品中允许使用。Table 2. Confirmation of fulfillment of chemical requirements表格 2，对化学品要求的确认Requirements Type of polymeric material Fulfils UsedSee IOS-MAT-0010 for specific (no use) (I
19、KEA information on each requirement 聚合材料的类型 满足 approval) 要求：参见 IOS-MAT-0010 各具体要求 (未使用) required)2使用（需宜家许 可） 2Biocides of all kinds, added in order to All impart properties to the final product 所有用于赋予最终产品性能的各种生物杀灭剂 Fragrances All 香精 所有Flame retardants All 2 阻燃剂 所有Does not Fulfils NotFulfil4 符合 appli
20、cable 不符合 不适用Alkylphenolethoxylates(APEO), AP, AP All phosphites and other AP derivatives 所有烷基苯酚聚氧乙烯醚，AP, AP 磷酸盐和其它 AP 衍生物 Self-declaration formPolymerics materialsSpec. nr: Date: Version nrIOS-MAT-00102013-05-10AA-10911-11 IKEA of Sweden AB 2013 Page 5Table 4. List of supporting documents表 4. 支持文件清
21、单Document文件Source(issuer of document)来源（文件签署人）Comments(optional)注释（可选）Table 3. Additional required information on Flame retardant used表 3. 阻燃剂使用的附加要求Trade name of flame retardant阻燃剂商品名称Manufacturer生产商名称Self-declaration formPolymerics materialsSpec. nr: Date: Version nrIOS-MAT-00102013-05-10AA-10911-
22、11 IKEA of Sweden AB 2013 Page 6This is to certify that we have read and understood IKEA specification IOS-MAT-0010 and that the materials listed in Table 1comply with IKEA requirements according to specification IOS-MAT-0010 (AA-10911-11) .兹证明我们已阅读及理解宜家技术规范 IOS-MAT-0010， 且列于表 1 的材料能够符合宜家技术规范 MAT-00
23、10 (AA-10911-11)的相关要求。Even if this form is signed by a sub-supplier（or sub-sub-supplier, ect） to the IKEA supplier, IOS-MAT-0010 as part of the Purchasing Agreement between IKEA and IKEA supplier always applies, and compliance is the final responsibility of the IKEA supplier in all cases.即使此文件是由宜家供应
24、商的下级供应商(或下-下级供应商，等 )签署，作为宜家和宜家供应商采购协议的一部分 IOS-MAT-0010 仍然适用，且在任何情况下，满足其要求仍是宜家供应商的最终责任所在。Name of final chemical processor(final formulator ) of thepolymeric material:聚合材料最终化学品处理方（最终成型方）： Address and phone no.(or supplier number, for IKEA supplier):联系地址和电话号码（如为宜家供应商，请提供供应商编号）：Place and date:时间和地点：Name and signature:姓名（正楷）和签名：
