Questionnaire De Vérification Des Matières Premières Selon Le Référentiel Des Cosmétiques

F349(GPA)v02en v. 01.04.2013 Questionnaire for non organic raw material checking according to the Natural origin and Organic CANDLES AND HOME FRAGRANCES

This questionnaire must be completed by the manufacturer of the raw material; Information given is under his own responsibility.

COMMERCIAL NAME:

I General information about your company and your product:

1. Raw Material manufacturer (address, telephone, fax) :

2. Supplier/Distributor, if different (address, telephone, fax) :

3. Category/Function :

4. Chemical formula :

5. CAS number:

6. INCI name:

II –Reagents origin and manufacturing processes:

1. Chemically processed ingredients:

For each chemically processed agro-ingredient, please answer the following questions: (Example: Glyceryl Stearate)

A Reagents List of reagents of plant origin, manufacturing process and content: - Glycerol, saponification of a vegetable oil, X% - Stearic acid, saponification, neutralization and distillation without solvent of a vegetable oil, X % - - List of reagents of mineral origin, manufacturing process and content: - - List of reagents of marine origin, manufacturing process and content: - - List of reagents of synthetic origin, manufacturing process and content: - - Indicate for each of the following processes whether it enters in the manufacturing of used reagents:

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ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com F349(GPA)v02en v. 01.04.2013

. Ethoxylation : YES NO . Irradiation : YES NO . Sulfonation : YES NO . Techniques using genetic manipulations : YES NO . Ethylene oxide treatment : YES NO . Treatment using mercury : YES NO . Extraction : YES NO (Specify the solvents used for extraction)

Do you use the following products among your reagents: MEA, DEA, TEA ? YES NO

Are all raw materials in bio technologic processes GMO free? YES NO Are the plants where reagents come from guaranteed GMO free ? YES NO

(Join a non-GMO attestation or a negative PCR analysis)

B Origin of manufacturing auxiliaries :

Indicate for each of the following processes whether it enters in the manufacturing auxiliaries (pH adjuster, catalyst …):

. Ethoxylation : YES NO . Irradiation : YES NO . Sulfonation : YES NO . Techniques using genetic manipulations : YES NO . Ethylene oxide treatment : YES NO . Treatment using mercury : YES NO . Extraction : YES NO (Specify the solvents used for extraction) :

Do you use the following products among your manufacturing auxiliaries : MEA, DEA, TEA ? YES NO

C Manufacturing process of the product to be validated:

Manufacturing process description :

Indicate for each of the following processes whether it enters in the product manufacturing: . Ethoxylation : YES NO . Irradiation : YES NO . Sulfonation : YES NO . Techniques using genetic manipulations : YES NO . Quaternization of YES NO .ecocert.com Page 2 sur 7

ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com F349(GPA)v02en v. 01.04.2013 . Ethylene oxide treatment : YES NO . Treatment using mercury : YES NO . Use of solvents for the manufacturing and the purification of your chemically transformed ingredient : YES NO . In that case, do you use aromatic, halogenated, sulfured, or nitrogened solvents ? YES NO (Specify the solvents used for extraction) :

. Hydrogenation : YES NO . Hydrolysis : YES NO . Esterification : YES NO . Etherification : YES NO . Sulphatation : YES NO . Fermentation : YES NO

Indicate the percentage of Active Matter of your chemically transformed ingredient:

D General questions regarding to the principles of green chemistry:

. Atoms economy principle: last reaction’s output R= (mass of the wanted product/mass of all products)*100 What is the result? (must be specified for all chemically processed agro- ingredients) R =

. During the manufacturing of your chemically transformed ingredient, are there intermediary reactions? YES NO Have you set up a procedure to reduce the number of these reactions? YES NO

E Other questions:

If your ingredient contains a synthetic moiety, as authorized in the Standard, appendix VI, Specify hereby the presence percentage of this moiety (on the active matter), as well as the ingredient involved:

2. Physically processed ingredients :

A Plant ingredients:

List here all the plant ingredients present in your raw material and their percentage as well as the manufacturing processes that were needed for their preparation: - Example: Sunflower oil, 5%, obtained by cold pressing - -

. Have a solvent of petrochemical origin been used for obtaining these ingredients: YES NO . If yes, which one? : .ecocert.com Page 3 sur 7

ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com F349(GPA)v02en v. 01.04.2013 . Are the plants initially used guaranteed GMO free? YES NO

B Animal origin ingredients:

List here all ingredients from animal origin present in your raw material and their percentage: - Example: Bees Wax, 5%. - -

. Are the ingredients listed above entailing the death of the animal?: YES NO

. Have a solvent of petrochemical origin been used for obtaining these ingredients: YES NO If yes, which one? :

C Mineral origin ingredients:

List here all ingredients from mineral origin of your raw material and their percentage, as well as the physical processes that were needed for their preparation: - Example: Calcium Carbonate, 5%, obtained by grinding. - -

. Are any of the ingredients listed above irradiated?: YES NO If yes, which ones (specify the type of irradiation also):

. Are all the ingredients listed above present in the appendix IV of the Standard? YES NO If no, specify which ones:

. Must these ingredients be labelled as nanoparticles on the cosmetic products according to the Cosmetic directive definition? YES NO If yes, which ones? :

D Synthetic origin ingredients:

List here all ingredients from synthetic origin present in your raw material, and their percentage: - Example: Sodium Benzoate, 0.1%. - -

ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com F349(GPA)v02en v. 01.04.2013 3. Additives :

. Present preservatives (names, origins, manufacturing processes and content (%) :

. Present antioxidants (names, origins, manufacturing processes and content (%) :

. Present solvents (names, origins, manufacturing processes and content (%) :

. Other additives (names, origins, manufacturing processes and content (%) :

4. Secondary constituents and impurities :

Indicate for each of the following constituents if it could be contained in the product (entering in the composition or sub product), if there is no data, indicate « ? » . 1.4-Dioxane: YES NO ? . Ethylene oxide: YES NO ? . Propylene oxide: YES NO ? . Monomers: YES NO ?

. Free amines :  Amidoamine (>0,5%): YES NO ?  Monoethanolamine (>0,5%): YES NO ?

. Heavy metals (cadmium, mercury, antimony, arsenic, chromium, cobalt, nickel, lead, silver) concentration > 10 ppm : YES NO ?

. Pesticides (-, -, -HCH, DDT, DDE, dichlofenthion, PCBs) YES NO ?

. Aromatic hydrocarbons: YES NO ?

. Other residues or impurities, specify :

ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com F349(GPA)v02en v. 01.04.2013 III Environmental and toxicology data:

1. General :

. Have you evaluated and established a procedure for limiting accident risks (human and environmental YES NO If yes, please detail these measures:

. Have you evaluated and established a procedure for the management of waste production (recycling and others) in the manufacturing of this raw material or for your manufacturing plant in general YES NO If yes, please detail these measures:

. Have you evaluated and established a procedure for energy economy in the manufacturing of this raw material or for your manufacturing plant in general?: YES NO If yes, please detail these measures:

2. Toxicology data :

. HET-CAM test:

. Data concerning skin irritation :

. Allergenic agents presence :

. Mutagenic agents presence :

3. Environmental data : (must be filled in for each chemically processed ingredients)

. Biodegradability OCDE series 301 :

. Water toxicity (bacteria, algae, daphnia, fish) :

ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com F349(GPA)v02en v. 01.04.2013

I undersigned, , representing the company, , declare that the information given in this questionnaire is correct.

Issued in , on the .

Obligatory signature (preceded by the mention « read and approved »)

ECOCERT Greenlife S.A.S. – Lieudit Lamothe Ouest BP 47 – 32600 L’Isle Jourdain France Capital 50 000€ - 509 534 095 RCS AUCH – www.ecocert.com