Supplier Form :
Commitment &
Declaration on
Dangerous
Substances
To be used as is U Reference : ENG-FRM-001
Version : E
Application date : April 17
Purpose
This document belongs to the process Engineering
Commitment to respect legal provisions relating to the marketing & the use of dangerous substances
Scope of application
The present document is applicable to all ALSTOM Transport Product Lines and their suppliers.
Responsibilities for the execution of this instruction
Accountable: Regions
Responsible for the appplication: Engineering, Sourcing
Responsible for the compliance: Suppliers
Contributors: Supplier Quality, EHS
Signatures
Name Position Date Signature
<Gwenaëlle
Written by : Ecodesign Engineer Date of signature Electronic signature
GRANVORKA>
<Amandine
Verified by : Sustainable Sourcing Manager Date of signature Electronic signature
NOURELDIN>
<Véronique
Approved by : Ecodesign Director Date of signature Electronic signature
ANDRIES>
Nota for Work Method Statements/ instructions (text to be removed when issuing the document):
* The verifier shall be:
The Site Quality Manager System to check coherence with other instructions and procedures applicable in his organisation
* The approver shall be :
The person who has authority to order implementation
431723109.xlsx Front page 01
Reference : REF-TEM-002
"Document Title" Application date in front page
Revision :7
Supplier's Declaration of Conformity : Declaration of respect of specifications on dangerous substances
The supplier is requested to fill in the form below, in order to ensure that the legal and contractual requirements concerning the dangerous substances are applied. This form is a compliance
1 commitment to ALSTOM requirements, as defined in the ENG-STD-003. This commitment covers all the references supplied to ALSTOM on the specified project.
The supplier is also requested to fill in the form called "Dangerous Substances Form" in order to declare the presence of dangerous substances in the supplied articles or preparations, according to
the section 1.2 of the specification ENG-STD-003.
2 This form must cover all the supplied references, for which the supplier must notice if dangerous substances (not only SVHC) are present.
For references that contain dangerous substances, the supplier must report all the requested about the present substances.
When relevant (e.g. change of composition, regulatory update) the information shall be updated.
This commitment declaration form shall be remitted at the tendering stage and the Dangerous Substances Form shall be remitted during the preliminary and detail design phase during which it will undergo the
different reviews. These forms shall also be filled in and remitted upon request out of the previously specified phases.
SUPPLIER AND SCOPE OF SUPPLY IDENTIFICATION (to be filled in by the supplier)
Name of supplier : Supplier name
Supplier address: Supplier address
Name of Project: Name of project
Scope of Supply: Scope of supply
ALSTOM Site requester Name of Alstom Site
Reference or order N° :
Order number
(to be filled in only when ordering)
GEOGRAPHIC LOCALISATION OF ACTIVITIES (to be filled in by the Tsick the relevant box
✘ in European Economic Area
For the scope of supply concerned in the declaration, the supplier activities are located
✘ out of European Economic Area
in European Economic Area
The purchasing/ assembly Alstom unit is located
✘ out of European Economic Area
in European Economic Area
The final customer is located
✘ out of European Economic Area
Please fulfill the form below corresponding to OUT OF the EEA activities
SUPPLIER'S DECLARATION OF CONFORMITY (according the ENG-STD-003)
If one of activities is located IN EEA, please fulfill the form below If all activities are located OUT OF EEA, please fulfill the form below
The supplier shall refer to the section 2 in ENG-STD-003 in order to answer to the form below The supplier shall refer to the section 3 in ENG-STD-003 in order to answer to the form below
ENG-STD- ENG-STD-
003 For all suppliers : Tick the relevant box 003 For all suppliers : Tick the relevant box
reference reference
A contact responsible of hazardous
A REACH contact person has been
substances has been appointed to be
appointed to be the contact for REACH YES YES
the contact for Hazardous substances
& Dangerous substances issues
issues
Section 2.3.a Section 3.3.a
Please give the contact details of this Contact details (e-mail address & Please give the contact details of this Contact details (e-mail address &
person telephone number) person telephone number)
Obligations related to REACH have Obligations related to hazardous
been identified and a regulatory watch substances regulation have been
Section 2.3.b YES Section 3.3.b YES
is carried out on REACH and CLP identified and a regulatory watch is
Regulations carried out .
All necessary actions have been All necessary actions have been
Section performed towards your own suppliers Section performed towards your own suppliers
YES YES
2.3.c in order to ensure your REACH 3.3.c in order to ensure your hazardous
compliance substances regulation compliance
All the legal and regulatory provisions
Obligations related to substances and
concerning the placing on the market
materials subject to restrictions and
Section 2.3.d YES Section 3.3.d and the use of certain hazardous YES
authorization are respected in all
substances are respected in all
activities locations
activities locations
Are the supplied substances (on their
own, in mixtures or in articles The Safety Data Sheet and relevant
releasing substances during normal exposure scenarios are updated when
Section 2, and foreseeable conditions of use) relevant and elaborated and
YES NA Section 3.3.e YES NA
paragraph 1 going to be registered, taking into transmitted in accordance with the
account the uses of ALSTOM Transport requirements of hazardous substances
for the Chemical Safety Report regulations.
elaboration ?
The Safety Data Sheet and relevant
exposure scenarios are updated when
The presence of hazardous substances
Section 2.3.e relevant and elaborated and YES NA Section 3.3.f YES
in its scope of supply are declared
transmitted in accordance to REACH
Regulation.
Does the supplier ensure that the The supplier confirm that he complies
specifications regarding substances to the specifications regarding
subject to authorization, listed in the YES hazardous substances, listed in the YES
Section 2.3.f, point 2, of the ENG-STD- Section 3.1; 3.2 & 3.3.f, of the ENG-
003, are met? STD-003
Section
Do you intend or need to ask for a Section 3.2 Do you intend or need to ask for a
2.3.f.2)
derogation concerning these YES NO derogation concerning these YES NO
substances ? substances (of concern)?
- If "Yes", please provide any - If "Yes", please provide any
Derogation information Derogation information
information concerning the derogation information concerning the derogation
Does the supplier ensure that the
specifications regarding substances
candidate to authorization, listed in YES
the Section 2.3.f, point 3, of the ENG-
STD-003, are met?
Section
2.3.f.3) Do you intend or need to ask for a
derogation concerning these YES NO
substances ?
- If "Yes", please provide any
Derogation information
information concerning the derogation
Does the supplier ensure that the
specifications regarding Substances
with SVHC criteria, listed in the YES
Section 2.3.f, point 4, of the ENG-STD-
003, are met?
Section
2.3.f.4) Do you intend or need to ask for a
derogation concerning these YES NO
substances ?
- If "Yes", please provide any
Derogation information
information concerning the derogation
Others D(FA) substances (referring to
Section
RISL) than Annex XIV, Candidates,
2.3.f.5) YES
SVHC criteria are declared for
assessment
Section Others hazardous substances
2.3.f.6) classified D(FI) (referring to RISL) are YES
declared for information
The supplier confirm that he complies
to the specifications regarding
Section 2.1;
hazardous substances, listed in the YES
2.2 & 2.3
Section 2.1; 2.2 & 2.3, of the ENG-
STD-003
ENG-STD-
For non-EU suppliers of substances or
003 Tick the relevant box
mixtures only :
reference
If relevant, do you have appointed an
Only Representative according to NON
YES NO
section 2.4 of the specification ENG- RELEVANT
STD-003 ?
Section 2.4 - If "non relevant", please provide
Justification for non relevance
short explanations
- If "Yes", please provide contact
Contact details
details of the Only Representative
SIGNATURE AND SEAL
must be signed by somebody authorized to engaged the company
Name of issuer : "Full name of issuer"
Function of issuer : "Function of issuer"
Place of issue : "Place of issue"
Date of issue : "Date of issue (dd/mm/yyyy)"
Version No "Version Number"
In witness
Signature : "Signature" whereof, signed
at :
UNCONTROLLED WHEN PRINTED – Not to be used before verification of applicable version number
Property of Alstom Transport - cannot be distributed or reproduced without authorization.
Name of supplier : Supplier name ALSTOM Transport site requester :
Project : Name of project
Information on Supplied Parts (Articles or Mixtures)
(delivered from Supplier to ALSTOM)
Sup
plie
Supplier Identification ALSTOM Transport
Part Designation (N) r
Number Identification Number
na
me
connector type A03 SuppX09990 DTR0000001234
connector type B09 SuppX09991 DTR0000012345
Example
paint blue AB SuppREF34567 DTR0000123456
Passenger Doors Supp0009001 CMN0098761234
sport site requester : Name of Alstom Site
DANGEROUS SUBSTANCES FORM : TAB
les or Mixtures) Information on the smallest article that
LSTOM) contains the substances (except mixtures)
ALSTOM Transport Article/material
Supplier of article that Article identification
drawing Number Designation
contains the substance number
(if any)
DID0000000001 Material Y Supplier Y
DID0000000002
CMD0000000003 Material A Supplier A 12345FG
Material B Supplier B 00001FT
NCES FORM : TABLE OF INFORMATION CONCERNING THE PRESENCE OF DANGEROUS
Information on Subst
Dangerous substances EC Number
CAS Number
(YES/NO) Only if no CAS n°
YES 84-69-5 201-553-2
NO
YES 1344-37-2 215-693-7
YES 1939-36-2 400-400-9
YES 123-77-3 204-650-8
YES 1313-27-5 215-204-7
YES 231-853-9 231-853-9
ENCE OF DANGEROUS SUBSTANCES
formation on Substances
Substance Name H Mentions
diisobutyl phthalate
Lead sulfochromate yellow
trimethylenediaminetetraacetic acid
C,C’-azodi(formamide) H334
molybdenum trioxide H351;H319;H335
silver nitrate H272;H314;H400;H410
Information on weight & weight
percentage
Weight percentage (w/w) of the
Substance classification on the substance in the article. Calculated
date of declaration according rules:
"Once an article, always an article"
D(FA) 0.4
P(AR) 1.5
D(FI) 7
D(FA) 0.15
D(FI) 0.1
D(FI) 0.05
n on weight & weight
percentage
Weight of article that contains
the substances
(in grams=g)
20
10000
10000
4200
4200
320
A – Definitions and References
A–1 Definitions
Þ EEA : European Economic Aera
Þ CAS N° : CAS N° of dangerous substance concerned (Chemical Abstract Service)
Þ EC N° : European inventory number of dangerous substance concerned (EINECS, ELINCS or NLP list)
Þ CLP Regulation : Regulation (CE) n°1272/2008 on classification, labelling and packaging of chemical
A–2 References Documents
The following documents are referenced through the text. For version or date specific references, subsequent am
to, or revisions of, any of these publications do not apply. Otherwise, the latest edition of the publication referred
applies.
[R1] ENG-STD-003 Instructions to Suppliers concerning the placing on the market and use of h
431723109.xlsx Definitions and reference 04
INCS or NLP list)
ging of chemicals
s, subsequent amendments
blication referred to
rket and use of hazardous substances
431723109.xlsx Definitions and reference 04
C - Control Sheet
Version Date Content of Modification Author
1 1-May-08 Cancel and replace
Modification DEV-FRM-001
of Commitment and Dangerous V. Andries
2 12/21/2009 ( first ref : MA-04-RS-FRM-002)
substances declaration I. Oujadou
Modification of Commitment and Dangerous
3 9/15/2011 Modificationsubstances declaration
of Commitment and Dangerous I. Oujadou
4 2/2/2017 substances declaration G. Granvorka
431723109.xlsx Control Sheet Page 05
Author
V. Andries
I. Oujadou
I. Oujadou
G. Granvorka
431723109.xlsx Control Sheet Page 05
