Certificate of Non-Use of The Controlled Substances (For Parts Approval) Rev. Jun2007

SAMPLE
Rev. Jun2007
Date:
2007/Jun/09
Certificate of Non-Use of The Controlled Substances
(For Parts Approval)
Please don't Change!
Please choose where you apply approval.
Company Name:__LITE-ON IT CORPORATION.______________________________________________
Section Name:
Signature or Stamp
is required.
Apply Approval in TWN: Technical Support Dept
Parts Supplier Name
Company Name: ABC SW Co. Ltd.
Name of Responsible Person:
The quality assurance
manager of the parts
Supplier
（Seal）.
ABC SW
Co. Ltd
AKIO SAITO
（Signature）
E-mail: Akio_Saito@ABC_sw.co.jp
End validation Date: 2008 / 11 / 30
Supplier GP ID (if yes,): OPP-1234
This is to certify that the materials, packaging and other constituents of the commodities delivered to you do not
use or contain any substances designated as Sony Requirements (SS-00259 Ver.6) Control Level 1 (Banned
Substances) for controlled applications.
It is hereby reported that the materials, packaging and other constituents of the commodities are composed of
the following components:
(1) Part and sub-material/unit part:
Part No.:
477-0039-1A
I
Important! Part and Sub-material Name:
Push SW
Part Weight (g): 3.00 g
a
Our customerSpec and Drawing No.: A-367-00HB
Production Plant:
Taiwan
V
requests
Drawing
p
<Materials used> Please attach the Please
disassembled
drawing, according to below table Number.
fill ID Number
1
Housing
1
POLYPLASTICS
Duranex 3105
Yes
0172
2
Terminal
1
Optiarc Metal
C3100
No
N/A
3
Contact
1
Optiarc Metal
C5210 / Ni plating
No
N/A
N/A
MSDS/
MIL sheet
etc. No.
Portion
weight (g)
Designated
(Y/N)
p
RMID
Material/
Type Name
ICP Data
No.
Multi-Source
Raw Material
Manufacturer
Portion No.
Multisources
that's in Raw Material
Vender List.
Portion/
Region
Name
N/A
MSDS
ICP1
1.00
N/A
MSDS2
N/A
0.10
MSDS3
N/A
0.10
MSDS4-1
ICP4-1
0.50
R1550172 MSDS4-2
ICP4-2
0.50
GB
Number
4-1
Stem
3
GE plastics
Noryl SE1V
Yes
0128
4-2
Stem
3
Mitsubishi Engineering Plastics
Iupiace AV60
Yes
0151A
4-3
Stem
3
Mitsubishi Engineering Plastics
NOVAMID 3021G30
Yes
0151
N/A
MSDS4-3
ICP4-3
0.50
5
Cover
1
Optiarc Metal
Tin Plate
No
N/A
N/A
MSDS5
N/A
0.30
6
Bracket
1
Optiarc Metal
Tin Plate
No
N/A
N/A
MSDS5
N/A
1.00
Remarks
Please fill out
* If there are more than 10 raw materials to fill in, please add as many rows
as necessary.
Green-Book
Number
if knows.
* Even Raw material Supplier has Sony Supplier GP certificates and G(B
umbers,
please fill in Material Manufacturer and Type Name also.
* In case Raw Material Supplier can’t be disclosed, Please use the Temporary Name like “Company A”, “Material 01”
and please fill in the reason into the remarks. => If not disclosed, the Letter to guaranty Raw material Supplier is required.
(2)Substances required for ICP measurement: Cadmium
and Lead in Plastics (including rubber), Paint and Ink
基於商業機密的考量，客戶可接受原材供應商保密(ex:
ICP measurement data required is attached on a separate sheet. Chemical Ingredient List or MSDS is
Company A)，但是必須說明保密原因於此份保證書
attached on a separate sheet.
裡。且要保證所用的原材製造商是GP。若是原因是合
理的話則可接受。
(3) Substances except for those above Chemical Ingredient List or MSDS is attached on a separate sheet.
(4) Zinc in the hot dip galvanization
1. Is any hot dip galvanized component used?
Yes / No
2. If it is used, please fill in the below table to confirm that it's electrolytic zinc. (Total:
0 portions)
< Confirmation of electrolytic zinc used>
Portion/
Region Number
Portion/
Region Name
Plating Company
Confirmation of electrolytic zinc
used.(Y/N)
Remarks
FE03B_OP
Rev. Jun2007
* If there are more than 3 raw materials to fill in, please add as many rows as necessary.
(5) Are the metals or alloys including zinc used?
Yes / No
If yes, please answer below
1. Is the brass used?
Yes / No
2. If yes, please check the box below
□ The free-machining brass rod is used
■ The free-machining brass rod is NOT used
If the free-machining brass rod is used, please fill in the below table. (Total: 0 portions)
< The free machining brass rod used>
Portion/
Region Number
Portion/
Region Name
Name of the manufacturer/model
Guaranteed figure of
cadmium content (ppm)
Remarks
* If there are more than 5 raw materials to fill in, please add as many rows as necessary.
(6) Electroless Nickel Plating
1. Is any electroless nickel plating used?
2. If it is, please fill in below table. (Total:
Yes / No
1 portions)
< Electroless Nickel Plating used>
Portion/
Region Number
Portion/
Region Name
Name of the manufacturer/model
the result of manufacturer's
simulation : Pb (ppm)
3
Contact
Japan Plating Liquid / JPL-001
> 100 ppm
Remarks
* If there are more than 10 raw materials to fill in, please add as many rows as necessary.
(7) Surface treatment (Chemical conversion treatment/ Chemical conversion coating, Chrome
plating/Chromium plating and others.)
1. Is any surface treatment (chemical conversion treatment/ chemical conversion coating, chrome plating/
chromium plating and others) used?
Yes / No
2. If it is used, fill in the below Table. (Total: 3 portions)
< Surface treatment used>
Portion/
Region Number
3
5
Portion/
Region Name
Contact
6
Plating Company
Process Name
Remarks
Cover
Osaki Plating Co. Ltd.
Company A
Ag Plating
Sn Plating
Company Secret
Bracket
Company A
Sn Plating
Company Secret
* If there are more than 10 raw materials to fill in, please add as many rows as necessary.
FE03B_OP
Rev. Jun2007
(8) WEEE requirements (Beryllium):
1. Is any “Beryllium Oxide” or “Other Forms of Beryllium” used?
2. If it is used, fill in the below Table. (Total: 1 portions)
Yes / No
< “Beryllium Oxide (BeO)” used> => Need to make sure the Location where BeO is used.
Portion/
Region Number
Portion/
Region Name
Please select
Level from
SS-00259 Ver.6
Detailed explanation of
the location of BeO
Remarks
* If there are more than 3 raw materials to fill in, please add as many rows as necessary.
< “Other Forms of Beryllium” used > => Need to make sure the Material Name of Other Form of Beryllium.
Portion/
Region Number
Portion/
Region Name
Material Name of
Other Form of Beryllium
3
Contact
BeCu-Alloy
Please select
Level from
SS-00259 Ver.6
Level3
Remarks
* If there are more than 3 raw materials to fill in, please add as many rows as necessary.
(9) Frame retardants:
1. Is any Frame retardants used?
Yes / No
2. If it is used, fill in the below Table. (Total: 4 portions)
< Frame retardant used>
Portion/
Region Number
Portion/
Region
Name
Frame
Retardant
Name
Grade of
flame
resistance
CAS No.
Halogen
Free (Y/N)
Yes
1
Housing
Glass Fiber
UL94-HB
Not details
4-1
Stem
Not details
UL94-V1
Not details
Yes
4-2
Stem
Phosphoric acid ester system fire retardant
UL94-V1
Confidential
Yes
4-3
Stem
Alumina Borosilicic acid nonalkali glass
UL94-HB
65997-17-3
Yes
Remarks
* If there are more than 10 raw materials to fill in, please add as many rows as necessary.
(10) PVC:
1. Is any PVC (Polyvinyl chloride) and PVC blends used?
2. If it is used, fill in the below Table. (Total: 0 portions)
Yes / No
<PVC and PVC blends used>
Portion/
Region Number
Portion/
Region Name
Material Name contain PVC
Grade of
flame
resistance
PVC ration
of Material
Portion (%)
SS-00259
regulation
Level
Remarks
* If there are more than 5 raw materials to fill in, please add as many rows as necessary.
*If you would like to write more for remarks, please write it below.
FE03B_OP
Rev. Jun2007
Sample of Required Drawing.
4-1
4-2
4-3
Part Weight (g):
Portion/
Region Number
Portion/
Region Name
1
2
3
4-1
4-2
4-3
5
6
Housing
Terminal
Contact
Stem
Stem
Stem
Cover
Bracket
RAW Material
PBT
Brass
Phosphorus bronze
PPHX
PPHX
6-6 Nylon
Tin Plate
Tin plate
RAW Material Manufacturer
POLYPLASTICS
Optiarc Metal
Optiarc Metal
GE plastics
Mitsubishi Engineering Plastics
Mitsubishi Engineering Plastics
Optiarc Metal
Optiarc Metal
Portion
weight (g)
1.00
0.10
0.10
0.50
0.50
0.50
0.30
1.00
3.00 g
Remark
Multi-Source
FE03B_OP