[별지 제3호서식 2매]

제한물질 또는 금지물질의 수출통보서

Export Notification of a Banned or Severely Restricted Chemical

※ 수출상품에 포함된 해당 물질별로 작성하여야 합니다.

1. Identification of the Importer
Country
Name
Address
Telephone Number
Facsimile Number
Electronic Mail Address
2. Identification of the Exporter
Country
Name
Address
Telephone Number
Facsimile Number
Electronic Mail Address
3. Identification of Chemical
<Information for a substance in the case of a mixture>
Common name
Chemical name according to IUPAC
Chemical Abstract Service(CAS) number
Trade names and names of preparation
Harmonized System(HS) customs code
Industrial use or uses
Properties	Summary of physico-chemical properties of the chemical
	Summary of toxicological properties of the chemical
	Summary of ecotoxicological properties of the chemical

<Information of a mixture>
Name of the mixture, if known
Concentration of the substance in the mixture
4. Information Respecting the Shipment
Expected dates of each shipment during the calendar year for which the export permit is issued
Port of exit of the substance
Names of the countries through which the substance will transit before arriving at its final destination
Quantities of the substance or mixture for each shipment
Expected total quantity of the substance or mixture that the exporter will export in that year
※ 첨부서류 : 각각의 대상물질에 대한 MSDS 2부
신고자 서명 (인)	유역(지방)환경청장 확인 (인)

※ 아래의 해당란은 지방환경관서 담당자가 기재하므로 신고자는 기재하지 마십시오.

5. Final Regulatory Action in Korea
The Chemical is	□ banned or □ severely restricted
<Information specific to the final regulatory action>
Summary of the final regulatory action
Reference to the regulatory document
Date of entry into force of the final regulatory action
6. Designated National Authority of Importing Country
Institution
Address
Facsimile Number
7. Relevant Designated National Authority in Korea
Institution		Hazardous Chemicals Management Division, Ministry of Environment
Address		Government Complex Kwacheon 1, Chungang-dong, Kwacheon, Kyunggi-do, Korea 427-729
Facsimile Number		+82-2-507-7654
※ Contact Point in Korea
Institution
Address
Facsimile Number