TSCA （有害物質規制法）フォームサンプル TOXIC SUBSTANCE CONTROL ACT (TSCA)
CERTIFICATION
Date: January 1, 2001 (CHECK ONE SECTION ONLY)
POSITIVE CERTIFICATION
X
いずれかに “Ｘ” をつけてください。 “I certify that all chemical substances in this shipment
comply with all applicable rules or orders under TSCA
and that I am not offering a chemical substance for
entry in violation of TSCA or any applicable rules
order thereunder.”
TSCA の規制に該当する貨物の場合 ●
OR
●
既存の化学品は POSITIVE CERTIFICATION となります
NEGATIVE CERTIFICATION
_________________________
“I certify that all chemical substances in this shipment
are not subject to TSCA.”
TSCA の規制に該当しない貨物の場合 天然の物質など Company Name:
ABC Corporation
（御社名）
Company Address:
1-2-3 Honcho
（御社ご住所）
City/State:
Chiyoda-ku Tokyo
（都市名）
Country/Zip:
Japan / 123-4567
（国名及び郵便番号）
Authorized Name:
Taro Yamada
（ご担当者の方のお名前）
Authorized Signature:
（サイン） Title:
Sales Manager
（役職名）
Federal Express AWB#: 1234-5678-9010
（弊社運送状番号） If the certifier is unsure if their chemical substance is subject to TSCA compliance,
contact the Environmental Protection Agency, TSCA Assistance Office, Washington,
D.C. (202) 554-1404 between 8:30 am and 5:00 pm EST.
TOXIC SUBSTANCE CONTROL ACT (TSCA)
CERTIFICATION
Date: ____________________________
(CHECK ONE SECTION ONLY)
POSITIVE CERTIFICATION
_________________________
“I certify that all chemical substances in this shipment
comply with all applicable rules or orders under TSCA
and that I am not offering a chemical substance for
entry in violation of TSCA or any applicable rules
order thereunder.”
●
OR
●
NEGATIVE CERTIFICATION
_________________________
“I certify that all chemical substances in this shipment
are not subject to TSCA.”
Company Name: ___________________________________________________
Company Address: __________________________________________________
City/State: ________________________________________________________
Country/Zip: _______________________________________________________
Authorized Name: __________________________________________________
Authorized Signature:
Title: _____________________________________________________________
Federal Express AWB#: _____________________________________________
If the certifier is unsure if their chemical substance is subject to TSCA compliance,
contact the Environmental Protection Agency, TSCA Assistance Office, Washington,
D.C. (202) 554-1404 between 8:30 am and 5:00 pm EST.
Revised 04-2009
toxic.392