<p> Receiving Volvo Company Date Report No. Supplier’s name and postal address INITIAL SAMPLE APPROVAL Result report</p><p>Dimension Material Function</p><p>Volvo Part No. / Issue complete unit</p><p>Supplier code no. Page 1 of pages</p><p>Supplier’s e-mail address and fax number Approved to delegated initial sample or PPAP level 1 according to Key Elements Procedure 2</p><p>Volvo Part No. / Issue Volvo Drawing No. / Issue Criticality [1] and/or regulatory demands yes no Description Reason for the initial sample test new supplier 2</p><p>Purchase order No. Purchase order date new part e r engineering changes DCN No. u d Number of samples Weight (average-gram) changed manufacturing conditions e c new manufacturing place o r long period of non-delivery ( more than 1 year ) P</p><p>Environmental declaration</p><p> s previous initial samples rejected t We confirm that no substances of those specified in Volvo’s black list n new/modified/refurbished tooling e (STD 100-0002) and the GADSL according to STD 100-0005 have change of 2nd Tier supplier parts m</p><p> e been used in this component. Reported in IMDS when ordered and/or l other : E</p><p> specified. Communicate phase-out plan to your Volvo contact. y e</p><p>K Name Signature</p><p> d n</p><p> a </p><p>1</p><p>For test records, see pages: , 6 The test results are placed in the same order as the numbers of the initial samples. 3 0 5</p><p>D T S</p><p>Comments Remarks o t</p><p> g n i d r o c c a g n i l d n</p><p> a We confirm, H 1. That the submitted samples are manufactured by completely serial production means and under serial production conditions. Decision : 2. That the performance of the initial sample test and its documentation Approved Interim approval Not approved in this report have been done correctly (deviations from this are Deliveries Delivieries allowed * New samples particularly stated in this report). allowed * but see remarks required</p><p>3. That an approval does not relieve the supplier from the Dept. Name Phone responsibility to always deliver in accordance with valid specifications 5 -</p><p>7 Name/Telephone (for enquiries) 8 1 6 1 3</p><p>1 7</p><p> o v l o V</p><p>B A</p><p>© Date Signature Date Signature Volvo fills in shaded areas. * For Renault Trucks and Volvo Powertrain France deliveries are only allowed after mountability and packaging approval </p>