1.

Producer/importer of the glass cullet:

Name:

Address:

Contact person:

Telephone:

Fax:

E-mail:

2.

1. (a)

   Name or code of the glass cullet category in accordance with an industry specification or standard:

2. (b)

   Main technical provisions of the industry specification or standard, including compliance with EoW product quality requirements for non-glass components, i.e. content of ferrous metals, non-ferrous metals, non-metal/non-glass inorganics and organics:

3.

The glass cullet consignment complies with the industry specification or standard referred to in point 2.

4.

Quantity of the consignment in kg:

5.

The producer of the glass cullet applies a management system complying with the requirements of Regulation (EU) No 1179/2012, which has been verified by an accredited conformity assessment body or by an environmental verifier or, where glass cullet which has ceased to be waste is imported into the customs territory of the Union, by an independent external verifier.

6.

The glass cullet consignment meets the criteria referred to in paragraphs 1 to 3 of Article 3 of Regulation (EU) No 1179/2012.

7.

The material in this consignment is intended exclusively for direct use in the production of glass substances or objects in re-melting processes.

8.

Declaration of the producer/importer of the glass cullet:

I certify that the above information is complete and correct and to my best knowledge:

Name:

Date:

Signature: