ANNEX III

1.

Producer/importer of scrap metal:

Name:

Address:

Contact person:

Tel.

Fax

E-mail:

2.

3.

The scrap metal consignment complies with the specification or standard referred to in point 2:

4.

Quantity of the consignment in tonnes:

5.

A radioactivity test certificate has been established in accordance with national or international rules on monitoring and response procedures for radioactive scrap metal:

6.

The producer of scrap metal applies a quality management system complying with Article 6 of Regulation (EU) No 333/2011 (1), which has been verified by an accredited verifier or, where scrap metal which has ceased to be waste is imported into the customs territory of the Union, by an independent verifier:

7.

The scrap metal consignment meets the criteria referred to in points (a) to (c) of Articles 3 and 4 of Regulation (EU) No 333/2011 (1):

8.

Declaration of the producer/importer of scrap metal: I certify that the above information is complete and correct to my best knowledge.

Name:

Date:

Signature: