Form 1-1; 1-2; 1-2A; 1- 1-1; 1-2; 1-2A; 1- CWC Schedule 1 Declarations and Reports

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)

DATE RECEIVED
(Leave Blank)

U.S. DEPARTMENT OF COMMERCE
Bureau of Industry and Security

CWC SCHEDULE 1
DECLARATION OR REPORT
CERTIFICATION FORM
Provide the information requested below in Questions C.1 through C.8.

C.1
C.2

Name of Declaration or Report Point of Contact (D/R-POC):
Company Name:
Mailing Address:

C.3

State:

City:
D/R-POC's Telephone Number:

C.4

Zip Code:
ext.

D/R-POC's Fax Number:
D/R-POC's E-mail Address:

C.5

Date Submitted (YYYY-MM-DD):

C.6

CERTIFICATION

I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the
submitted information is true and complete.
Name and title of responsible official (type or print):
Signature:

Date Signed (YYYY-MM-DD):
TYPE OF DECLARATION OR REPORT

(check one box, except check two boxes for an amendment)

INITIAL DECLARATION:
Previously declared facility for production of more than 100 grams aggregate of Schedule 1 chemicals
New facility or existing facility anticipating to produce more than 100 grams aggregate of
Schedule 1 chemicals (YYYY):___________

C.7

ANNUAL DECLARATION ON PAST ACTIVITIES (YYYY):___________
ANNUAL REPORT ON EXPORTS AND IMPORTS (YYYY):___________
COMBINED ANNUAL DECLARATION AND REPORT (YYYY):___________
ANNUAL DECLARATION ON ANTICIPATED ACTIVITIES (YYYY):___________
AMENDMENT

Forms Submitted

C.8

Check all forms that are included:
FORM 1-1

FORM 1-2

FORM 1-2A

FORM 1-2B

FORM 1-3

FORM 1-4

FORM A
FORM B

CERTIFICATION FORM Schedule 1 Declaration or Report
Declaration and reporting requirements are set forth in Part 712
of the CWC Regulations (15 CFR 712).
A separate Certification Form is required for:
a) each Schedule 1 facility that has declaration requirements
(declared facility);
b) each Schedule 1 facility with reporting requirements
(undeclared facility); and
c) each trading company with Schedule 1 reporting
requirements.
NOTE: If you submit a combined declaration and report, you
must submit only one Certification form.
This form serves several purposes, including:
a)
b)
c)
d)

identifying a Point of Contact;
certifying the accuracy of the submitted declaration;
identifying the type of declaration submitted; and
listing the declaration forms submitted.

Questions C.1 through C.5 Name of Declaration or Report
Point of Contact (D/R-POC) and Other Requested Information:
Designate a D/R-POC. The D/R-POC should be a person
whom the Department of Commerce may contact for: (1) the
purposes of clarification of information provided in the
declaration or report; and (2) for general information. The
D/R-POC need not be the person who prepares the forms or
signs the Certification Form.
Question C.6 Certification: The Certification must be signed
and dated by the owner, the operator, or a senior management
official who certifies the accuracy and completeness of the
information submitted. The Certification signature block must
contain an original signature.
Question C.7 Type of Declaration or Report: Check the box for
the type of declaration or report being submitted (e.g., initial,
past activities, anticipated activities, exports and imports,
combined declaration and report, and amendments) and
indicate the year for which the information applies.
The INITIAL DECLARATION provides a technical
description of the declared Schedule 1 facility or its relevant
parts. An initial declaration is required if your facility
produced or is anticipating to produce more than 100 grams

aggregate of Schedule 1 chemicals. You are required to submit
a current technical description of your facility or its relevant
parts, including a narrative statement and detailed diagrams of
the declared area(s). There are two types of Initial
Declarations:
1) A facility previously declared in February 2000 that
produced more than 100 grams aggregate of Schedule 1
chemicals. NOTE: If you anticipate to make significant
changes (e.g., relocation of the facility or its relevant parts,
expansion of declared areas) to your initial declaration, you
must submit an amended declaration describing such
changes not less than 200 days before you implement such
changes.
2) A newly established facility or a previously undeclared
existing facility that anticipates it will produce more than 100
grams aggregate of Schedule 1 chemicals. NOTE: You are
required to submit your Initial Declaration 200 days in
advance of commencing such production.
The ANNUAL DECLARATION ON PAST ACTIVITIES
provides information on the production, consumption,
storage, and domestic transfer of Schedule 1 chemicals by a
declared Schedule 1 facility for the previous calendar year. A
facility must submit an ANNUAL DECLARATION ON PAST
ACTIVITIES if the facility produced more than 100 grams
aggregate of Schedule 1 chemicals.
The ANNUAL REPORT OF EXPORTS AND IMPORTS
provides detailed information on exports and imports of
Schedule 1 chemicals to or from other States Parties.
The COMBINED ANNUAL DECLARATION AND
REPORTprovides production data required for an Annual
Declaration on Past Activities and export and import data
required for an Annual Report on Exports and Imports.
The ANNUAL DECLARATION ON ANTICIPATED
ACTIVITIES provides information on anticipated production
in the next calendar year of each Schedule 1 chemical and the
purposes for which each will be used. You must submit this
declaration if you anticipate producing more than 100 grams
aggregate of Schedule 1 chemicals at your previously declared
facility in the next calendar year.
Question C.8 Forms Submitted: Check the appropriate box for
each form that is included in the submission.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
FACILITY OR TRADING COMPANY NAME:

CWC SCHEDULE 1
DECLARATION OR REPORT

U.S. FACILITY OR TRADING COMPANY CODE
(once assigned):

FORM 1-1 SCHEDULE 1 FACILITY OR TRADING COMPANY IDENTIFICATION
Submit this form for each declared Schedule 1 facility, undeclared Schedule 1 facility, or trading
company. You must submit this form for each type of declaration or report (initial, past activities,
anticipated activities, exports and imports, combined, and amendments).
Owner:

1-1.1

Telephone Number:

Fax Number:

Operator:

1-1.2

Telephone Number:
Building Name or Structure Number:

1-1.3

Fax Number:

Street Address:

1-1.4

City:

State:

Zip Code:

Provide the geographic coordinates of the center of the facility (see Supplement No. 1).
a. Latitude (Deg/Min/Sec/N):

1-1.5

b. Longitude (Deg/Min/Sec/W):
For the Initial Declaration (declared facilities only) check the appropriate box and provide the
required information as an attachment to Form A.

1-1.6

Detailed Technical Description of Facility

Changes to the Detailed Technical Description

Designation of Inspection Point of Contact (I-POC) for inspection notifications involving this facility.
NOTE: The Department of Commerce must be able to reach the I-POCs at all hours through the
telephone numbers shown below.
Name of I-POC:

1-1.7.1

I-POC's Primary Telephone Number:

ext.

I-POC's Alternate Telephone Number:

ext.

I-POC's Fax Number:
I-POC's E-mail Address:
Name of Alternate I-POC (optional):

1-1.7.2

I-POC's Primary Telephone Number:

ext.

I-POC's Alternate Telephone Number:

ext.

I-POC's Fax Number:
I-POC's E-mail Address:

FORM 1-1 Schedule 1 Facility or Trading Company Identification
Declaration and reporting requirements are set forth in Part 712
of the CWC Regulations (15 CFR 712).
Submit this form for each declared Schedule 1 facility,
undeclared Schedule 1 facility, or trading company. Declared
Schedule 1 facilities must submit this form for each type of
declaration (initial, past activities, combined annual declaration and report, anticipated activities, and amended) and
complete questions 1-1.1 through 1-1.7 as appropriate.
Undeclared Schedule 1 facilities and trading companies must
complete questions 1-1.1 through 1-1.4 to satisfy their annual
export and import reporting requirements.
Submit Form A to identify any additional information (e.g., site
diagrams, maps, drawings, chemical structural formulas) you
submit with your completed forms package.
For the INITIAL DECLARATION, submit the Certification
Form, this Form 1-1, and Form A. You must also provide and
attach to Form A a technical description of your facility or its
relevant parts. On Form 1-1, you must complete questions
1-1.1 through 1-1.7.
For the ANNUAL DECLARATION ON PAST ACTIVITIES,
submit the Certification Form, Form 1-1, Forms 1-2, 1-2A, 1-2B,
1-3, and Form A, as appropriate. On Form 1-1, you must
complete questions 1-1.1 through 1-1.5, and 1-1.7.
For the ANNUAL REPORT ON EXPORTS AND IMPORTS,
submit the Certification Form, Form 1-1, and Form 1-3. On
Form 1-1, you must complete questions 1-1.1 through 1-1.4.
For the COMBINED ANNUAL DECLARATION AND
REPORT, submit the Certification Form, Form 1-1, Form 1-2,
(Form 1-2A and 1-2B as appropriate) and Form 1-3. On Form
1-2, you must complete questions 1-1.2 through 1-1.5, and
1-1.7
For the ANNUAL DECLARATION ON ANTICIPATED
ACTIVITIES, submit the Certification Form, Form 1-1, and
Form 1-4. On Form 1-1, you must complete questions 1-1.1
through 1-1.5, and 1-1.7.
For amended declarations or reports, submit the Certification
Form, Form 1-1, and the applicable form(s) being amended. If
you are changing the technical description of your facility
previously submitted with your Initial Declaration, you must
complete 1-1.6 as well as all other questions on this Form 1-1.

All submitters should assign a unique name to the facility or
trading company, and record this name in the appropriate box
in the upper right-hand corner of Form 1-1. The Department of
Commerce will provide each submitter with a unique code.
This code, hereafter referred to as a “U.S. Facility or Trading
Company Code,” will be the primary means of identifying a
facility after the Initial Declaration or the first Report on
Exports and Imports is submitted and the Department of
Commerce assigns a code. The submitter should use this code
on all future declarations or reports.
Questions 1-1.1 through 1-1.4: Provide the name and
telephone and fax numbers of the owner and the operator or
the occupant or the agent in charge of the facility or the
trading company. Provide the Building Name or Structure
Number of the facility or the trading company and the address.
DO NOT PROVIDE A POST OFFICE BOX.
Question 1-1.5: Provide the latitude and longitude for the
center of the facility using the following formats (see
Supplement No. 1 for guidelines on determining geographic
coordinates):
Latitude:
Longitude:

000(degree)/00(minutes/00(seconds)/N
000(degree)/00(minutes/00(seconds)/W

NOTE: If your geographic coordinates do not represent the
center of the facility, you must clearly explain in your detailed
technical description the location of your coordinates (e.g.,
Room 2 in Building 7). You should name this section of your
detailed technical description “Geographic Coordinates.”
Question 1-1.6: Check the appropriate box to indicate if you
are providing a detailed technical description of your facility
or its relevant parts as part of your Initial Declaration, or
changes to the technical description previously submitted.
For the Initial Declaration, you must submit a current detailed
technical description of your facility or its relevant parts,
including: (1) narrative statement; and (2) detailed diagrams of
the declared area(s). Attach this information to Form A.
Questions 1-1.7.1 & 1-1.7.2: Designate an Inspection Point of
Contact (I-POC) and provide telephone and fax numbers, and
an e-mail address so the Department of Commerce may notify
you of inspections of your facility. You may also designate an
Alternate I-POC. The Department of Commerce must be able
to contact the I-POCs on a 24 hour basis.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
FACILITY NAME:

CWC SCHEDULE 1
DECLARATION

U.S. FACILITY CODE (once assigned):

FORM 1-2 DECLARATION ON SCHEDULE 1 CHEMICAL ACTIVITIES AT THE
FACILITY DURING THE PREVIOUS YEAR
Submit this form for each Schedule 1 chemical produced, stored, and/or consumed by, and
domestically transferred from the declared Schedule 1 facility.
CHEMICAL NAME:

CAS REGISTRY NO.:

Check this box if you have attached a structural formula for this chemical to Form A.
Quantity Produced: ______________ grams

1-2.1
NOTES: 1. You may not produce a Schedule 1 chemical for protective purposes.
2. If this Schedule 1 chemical was produced, also submit Form 1-2A.
Quantity Consumed: ______________ grams
Purpose(s) of Consumption:

1-2.2

RESEARCH

PHARMACEUTICAL

WASTE DISPOSAL

PRODUCTION OF OTHER SCHEDULE 1 CHEMICAL

1-2.3
1-2.4
1-2.5

MEDICAL

PROTECTIVE

Maximum quantity stored at any time during the previous calendar year:

grams

Quantity stored at previous calendar year end (as of 12-31)

grams

a. Was the chemical transferred to other facilities in the U.S. during the previous calendar year?
b. If yes, give the total quantity transferred (also submit Form 1-2B):

grams

YES

NO

FORM 1-2 Declaration on Schedule 1 Chemical Activities at the Facility during the Previous Year
Declaration and reporting requirements are set forth in Part 712
of the CWC Regulations (15 CFR 712).
If you produced more than 100 grams aggregate of Schedule 1
chemicals during the previous calendar year, you are a
declared Schedule 1 facility and must submit Form 1-2. Note:
Undeclared Schedule 1 facilities and trading companies that
have reporting requirements for exports or imports of
Schedule 1 chemicals are not required to submit Form 1-2.
FOR THE ANNUAL DECLARATION ON PAST ACTIVITIES,
you must submit a separate Form 1-2 for each Schedule 1
chemical you produced, consumed, stored and/or transferred
domestically from your facility in any quantity during the
previous calendar year.
Submit Form A to identify any additional information (e.g.,
chemical name, chemical structural formula) you submit with
your completed forms package.
In the upper right-hand corner of this form, enter the facility
name or U.S. facility code (once assigned) that you entered on
Form 1-1 (Schedule 1 Facility or Trading Company
Identification).
For each Schedule 1 chemical being declared, provide the CAS
Registry Number, if assigned, and the Chemical Name. If the
chemical is not specifically listed by Chemical Name and CAS
Registry Number in Supplement No. 1 to Part 712 of the CWC
Regulations (15 CFR 712), you must attach the structural
formula of the chemical to Form A. Check the box to indicate
that you have attached the structural formula.
Question 1-2.1: Identify the quantity of the Schedule 1
chemical produced at the facility during the previous calendar
year. Report the quantity of the chemical to the nearest gram.

NOTE:
1) You may not produce Schedule 1 chemicals for protective
purposes.
2) If this Schedule 1 chemical was produced, you must also
submit a Form 1-2 A.
Question 1-2.2: Identify the quantity of the Schedule 1
chemical consumed by the facility during the previous
calendar year. Report the quantity of the chemical to the
nearest gram. Check the appropriate box(es) to identify the
purpose(s) for which the chemical was consumed.
Question 1-2.3: Identify the maximum quantity of the Schedule
1 chemical stored at any time at the facility during the previous
calendar year. Report the quantity of the chemical to the
nearest gram. The quantity reported should include all types
of storage (e.g., tanks, process vessels, on-site shipping
containers) at the declared facility.
Question 1-2.4: Identify the quantity of the Schedule 1
chemical stored at the facility at the end of the previous
calendar year (i.e., the quantity stored on December 31 of the
reporting year). Report the quantity of the chemical to the
nearest gram.
Question 1-2.5: Identify whether this facility transferred the
Schedule 1 chemical to other facilities in the United States
during the previous calendar year, and the aggregate quantity
(rounded to the nearest gram) involved in the transfers. If
transfers within the United States did occur, also complete
form 1-2B for each transaction. NOTE: Do NOT check the
“yes” box in question 1-2.5 if your company exported (i.e.,
transferred the chemical to a recipient outside the United
States) the Schedule 1 chemical. Exports should be recorded
on Form 1-3.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
FACILITY NAME:

CWC SCHEDULE 1
DECLARATION

U.S. FACILITY CODE (once assigned):

FORM 1-2A DECLARATION ON SCHEDULE 1, 2, AND 3 PRECURSOR CHEMICAL(S)
USED TO PRODUCE A SCHEDULE 1 CHEMICAL
Submit this form for each Schedule 1 chemical produced by the declared Schedule 1 faciilty using one or
more precursor chemicals listed on Schedules 1, 2, or 3.
CAS REGISTRY NO.:

CHEMICAL NAME:

Provide the following information for each precursor chemical used by this facility to produce
this Schedule 1 chemical.
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.1
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.2
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.3
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.4
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.5
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.6
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.7
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.8
grams
a. Precursor Chemical Name:

b. CAS Registry No.:

c. Quantity Used

1-2A.9
grams

FORM 1-2A Declaration on Schedule 1, 2, and 3 Precursor Chemical(s) Used to Produce Schedule 1
Chemical
Submit this form for each Schedule 1 chemical you produced at
your declared Schedule 1 facility using one or more Schedule
1, 2 or 3 precursor chemicals. Do not submit a Form 1-2A for a
Schedule 1 chemical unless you provided production
information in response to question 1-2.1 on Form 1-2.
For each Schedule 1 chemical being declared, provide the CAS
Registry Number, if assigned, and the Chemical Name. NOTE:
This is the same information as provided in Form 1-2 above.

Question 1-2A.x.a: Identify the Schedule 1, 2, or 3 precursor
chemical(s) used by this facility to produce the Schedule 1
chemical.
Question 1-2A.X.B: Provide the corresponding CAS Registry
Number for the precursor chemical.
Question 1-2A.x.c: Identify the quanitity to the nearest gram
of the Schedule 1, 2, or 3 precursor chemical used to produce
the Schedule 1 chemical.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
FACILITY NAME:

CWC SCHEDULE 1
DECLARATION

U.S. FACILITY CODE (once assigned):

FORM 1-2B DECLARATION ON TRANSFERS OF SCHEDULE 1 CHEMICAL TO OTHER
FACILITIES IN THE UNITED STATES
Submit this form for each Schedule 1 chemical that was transferred to another facility in the United
States during the previous calendar year.
CHEMICAL NAME:

CAS REGISTRY NO.:

Check this box if you have attached a structural formula for this chemical to Form A.

Provide the following information for each domestic transfer of this Schedule 1 chemical.
a. Name of recipient company:
b. Street Address:
City:

Zip Code:

State:

1-2B.1

grams

c. Quantity:
d. Purpose(s):
RESEARCH

PHARMACEUTICAL

WASTE DISPOSAL

PRODUCTION OF OTHER SCHEDULE 1 CHEMICAL

MEDICAL

PROTECTIVE

a. Name of recipient company:
b. Street Address:
City:

1-2B.2

Zip Code:

State:
grams

c. Quantity:
d. Purpose(s):
RESEARCH

PHARMACEUTICAL

WASTE DISPOSAL

MEDICAL

PROTECTIVE

PRODUCTION OF OTHER SCHEDULE 1 CHEMICAL

a. Name of recipient company:
b. Street Address:
City:

1-2B.3

Zip Code:

State:

c. Quantity:

grams

d. Purpose(s):
RESEARCH

PHARMACEUTICAL

WASTE DISPOSAL

PRODUCTION OF OTHER SCHEDULE 1 CHEMICAL

MEDICAL

PROTECTIVE

If additional pages of Form 1-2B for this chemical are attached, indicate the total number of pages as follows:
page _________ of _________ (e.g., page x of y)

FORM 1-2B Declaration on Transfers of Schedule 1 Chemical to Other
Facilities in the United States
Declaration and reporting requirements are set forth in Part 712
of the CWC Regulations (15 CFR 712).
Submit Form 1-2B to declare each domestic transfer of a
Schedule 1 chemical to another facility in the United States
during the previous calendar year. You must separately
declare each transfer of a Schedule 1 chemical to another
facility during the previous year (e.g., if you made four
transfers of the same Schedule 1 chemical to the same
company in the previous year, you must separately declare
each of those four transfers).
Do not submit this form unless you answered "yes" to
question 1-2.5 on Form 1-2 for this Schedule 1 chemical. Form
1-2B, if applicable, is part of your ANNUAL DECLARATION
ON PAST ACTIVITIES.
Submit Form A to identify any additional information (e.g.,
chemical name, chemical structural formula) you submit with
your completed forms package.
In the upper right-hand corner of this form, enter the facility
name or U.S. facility code (once assigned) that you entered on
Form 1-1 (Schedule 1 Facility or Trading Company
Identification).
For each schedule 1 chemical being declared, provide the CAS
Registry Number, if assigned, and the Chemical Name. If the

chemical is not specifically listed by Chemical Name and CAS
Registry Number in Supplement No. 1 to Part 712 of the CWC
Regulations (15 CFR 712), you must attach the structural
formula of the chemical to Form A. Check the box to indicate
that you have attached the structural formula.
Question 1-2B: Provide the information in Question 1-2B.x.a
through 1-2B.x.d for each domestic transfer of this Schedule 1
chemical.
Question 1-2B.x.a: Enter the name of the company that
received the Schedule 1 chemical.
Question 1-2B.x.b: Enter the address of the recipient company
listed in Question 1-2B.X.a. DO NOT PROVIDE A POST
OFFICE BOX.
Question 1-2B.x.c: Enter the quantity of the transaction in
grams.
Question 1-2B.x.d: Check the purpose intended for the
transferred Schedule 1 chemical.
If there is insufficient space to record all of your domestic
transfers, use additional copies of Form 1-2B. Indicate the
page number of each additional page and total the number of
pages of Form 1-2B for this chemical using the format “page x
of y” (as described at the bottom of this form).

FORM 1-3 Declaration or Report on Schedule 1 Chemical Exported to
or Imported From Other States Parties
Declaration and reporting requirements are set forth in Part 712
of the CWC Regulations (15 CFR 712).
Submit this form for each Schedule 1 chemical that you
exported to or imported from another State Party to provide
detailed information on each trade transaction. Use a separate
Form 1-3 for each Schedule 1 chemical. NOTE: There is no
exclusion or de minimis amount for declaring or reporting
Schedule 1 chemical exports or imports.
Declared facility. If you are a declared Schedule 1 facility,
submit this Form 1-3 as part of your COMBINED ANNUAL
DECLARATION AND REPORT.
Undeclared facilities and trading companies. If you are an
undeclared Schedule 1 facility or trading company, submit this
Form 1-3 as part of your ANNUAL REPORT ON EXPORTS
AND IMPORTS.
Submit Form A to identify any additional information (e.g.,
chemical name, chemical structural formula) you submit with
your completed forms package.
In the upper right hand corner of this form, enter the facility or
trading company name or U.S. Facility or Trading Company
Code (once assigned) that you entered on Form 1-1 (Schedule
1 Facility or Trading Company Identification).
For each Schedule 1 chemical being declared, provide the CAS
Registry Number, if assigned, and the Chemical Name. If the
chemical is not specifically listed by Chemical Name and CAS

Registry Number in Supplement No. 1 to Part 712 of the CWC
Regulations (15 CFR 712), you must attach the structural
formula of the chemical to Form A. Check the box to indicate
that you have attached the structural formula.
Question 1-3.1.x.a: Check the appropriate box to indicate
whether this trade transaction was an export or an import.
Question 1-3.1.x.b: Enter the name of the recipient or source of
the Schedule 1 chemical in the other State Party.
Question 1-3.1.x.c: Enter the address of the recipient or source
of the Schedule 1 chemical identified in b. above. Use the
Destination Codes in Supplement 3 to identify the other State
Party to the export or import.
Question 1-3.1.x.d: Check the appropriate box(es) to indicate
the intended purpose(s) for the Schedule 1 chemical.
Question 1-3.1.x.e: Enter the quantity of the Schedule 1
chemical exported or imported in grams.
Question 1-3.1.x.f: Enter the date the Schedule 1 chemical
cleared U.S. Customs for export or import.
If there is an insufficient amount of space to record all of your
export and import transactions of this chemical, use additional
copies of Form 1-3. Indicate the page number of each
additional page and the total number of pages using the format
“page _ of _” (as described at the bottom of this form).

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
FACILITY NAME:

CWC SCHEDULE 1
DECLARATION

U.S. FACILITY CODE (once assigned):

FORM 1-4 DECLARATION ON SCHEDULE 1 ANTICIPATED ACTIVITIES
Submit this form for each Schedule 1 chemical anticipated to be produced at this Schedule 1 facility.
CAS REGISTRY NO.:

CHEMICAL NAME:

Check this box if you have attached a structural formula for this chemical to Form A.

1-4.1

Anticipated Production Quantity:

grams

Anticipated Purpose(s):

1-4.2

RESEARCH

PHARMACEUTICAL

WASTE DISPOSAL

PRODUCTION OF OTHER SCHEDULE 1 CHEMICAL

1-4.3

Starting Date (YYYY-MM):

Ending Date (YYYY-MM):

Starting Date (YYYY-MM):

Ending Date (YYYY-MM):

Starting Date (YYYY-MM):

Ending Date (YYYY-MM):

Starting Date (YYYY-MM):

Ending Date (YYYY-MM):

Starting Date (YYYY-MM):

Ending Date (YYYY-MM):

Starting Date (YYYY-MM):

Ending Date (YYYY-MM):

MEDICAL

FORM 1-4 Declaration on Schedule 1 Anticipated Activities
Declaration and reporting requirements are set forth in Part 712
of the CWC Regulations (15 CFR 712).

formula of the chemical to Form A. Check the box to indicate
that you have attached the structural formula.

Submit this form if you anticipate to produce Schedule 1
chemicals in excess of 100 grams aggregate at the declared
facility in the next calendar year.

Question 1-4.1.1: Provide the quantity of each Schedule 1
chemical that you anticipate to produce during the next
calendar year.

In the upper right hand corner of this form, enter the facility
name or U.S. Facility Code (once assigned) that you entered
on Form 1-1 (Schedule 1 Facility or Trading Company
Identification).

Question 1-4.1.2: Check the appropriate box(es) to indicate the
anticipated purposes for the Schedule 1 chemical.

For each Schedule 1 chemical being declared, provide the CAS
Registry Number, if assigned, and the Chemical Name. If the
chemical is not specifically listed by Chemical Name and CAS
Registry Number in Supplement No. 1 to Part 712 of the CWC
Regulations (15 CFR 712), you must attach the structural

NOTE: You may not produce Schedule 1 chemicals for
protective purposes.
Question 1-4.1.3: Provide the starting and ending dates for
each of the anticipated periods of production of the Schedule
1 chemical at this Schedule 1 facility.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)

COMPLETE AS MANY COPIES OF THIS FORM AS NECESSARY.

CWC SCHEDULE 1
FORM A

Use this form to describe any attachment to this declaration or report. The Initial
Declaration requires attachment of a technical description of the Schedule 1
facility. Attachments may include, for example, any additional information on
the precise location of a facilty, site map, structural formula for a chemical.

FORM A ATTACHMENTS FOR SCHEDULE 1 FACILITY
OR TRADING COMPANY
Form Number

Facility or Trading Company Name:

Identify each attachment with a unique name or description.

FORM A Attachments for Schedule 1 Facility or Trading Company
Declaration and reporting requirements are set forth in Part 712 of the CWC Regulations (15 CFR 712).
Submit this form to list any attachments containing additional information (e.g., site diagrams, structural formula for a Schedule 1
chemical).
As required by Form 1-1 for the INITIAL DECLARATION, you must use this form to list the documents that provide a detailed
technical description of the declared facility or its relevant parts. The technical description for each declared facility or its relevant
parts must include the following information: (1) narrative statement describing the facility; and (2) detailed diagram(s) of the declared
areas. (Note: If the diagram includes any areas which are not declared, you should clearly distinguish between the declared and nondeclared areas). Submission of additional attachments to further characterize the site and to clarify its exact location is on a voluntary
basis. Note that undeclared Schedule 1 facilities and trading companies should also use Form A to provide attachments.
Insert all attachments into an envelope and staple the envelope to Form A.
FACILITY NAME: Enter the name of the facility or trading company, and if assigned, enter its U.S. Facility Code.
FORM NUMBER: In column 1, enter the form number to which the additional information refers.
IDENTIFY THE ATTACHMENT WITH A UNIQUE NAME OR DESCRIPTION: In column 2, assign a unique name and/or description
to identify each attachment. For structural formulas, provide the CAS Registry Number, if assigned, and/or Chemical Name.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)

CWC SCHEDULE 1
FORM B
FORM B OPTIONAL COMMENTS
Comments on form number ____________, question number ______________:

B.1.1

Comments on form number ____________, question number ______________:

B.1.2

Comments on form number ____________, question number ______________:

B.1.3

Comments on form number ____________, question number ______________:

B.1.4

Comments on form number ____________, question number ______________:

B.1.5
Comments on form number ____________, question number ______________:

B.1.6

General comments or suggestions:

B.2.1

FORM B Optional Comments
Declaration and reporting requirements are set forth in Part 712 of the CWC Regulations (15 CFR 712).
Please use this form to record comments or suggestions. Use as many copies of this form as necessary. Submission of this form is
optional, and the information provided will only be used by the Department of Commerce to improve the forms and the CWC reporting
process.