This form is used when you fill in one parts or one material (date) day/month/year

RoHS prohibited substances content measurement result

Supplier’s cord：

Parts name： Company：

Parts number： Accountable person： seal

Parson in charge： seal

Result of measurement (fill in the value by using the unit of ppm)

component name	material (name/type)	Producing country	maker/factory	Value of measurement[ppm]
(raw material)	Cd	Pb	Hg	Cr６+	PBBs	PBDEs	DEHP	BBP	DBP	DIBP
(processing)

Please attach precise analysis data of the analysis organization.

Sanken Procurement Division check field

confirmation	examination	making

The above-mentioned value was confirmed.

(date)

QC352B-1