Trade and Industry Department
	Government of the Hong Kong Special Administrative Region
	Chemical Weapons (Convention) Ordinance (Cap. 578)		
REPORT OF TECHNICAL DETAILS OF A FACILITY (FORM S1)	
Part A :	Details of the facility (Note 1) 	
Name :	     	Permit number :
(if applicable)	     	
Address :	     	Tel no.	:	     	
		Fax no.	:	     	
Part B :	Purposes of the facility	
Purpose(s) of carrying out the activities for Schedule 1 chemicals in the facility declared in Part A above (please mark ‘X’ if applicable):	
 Research 	 Medical 	 Pharmaceutical	 Protective 	 Waste disposal	 Production of other Schedule 1 chemicals
 Others (please specify) :      	
Part C :	Technical description of the facility and its relevant areas (Guideline 8 and use additional Form S1 if necessary)	
Detailed narrative statement (please attach detailed diagrams of the facility) :
     	
Inventory of equipment in each of the above declared area(s) :
     	
Part D :	Total number of Form S1 submitted (including this page) :        	 pages 	
Part E : Undertaking	
I, the undersigned, signing for and on behalf of the above named facility, declare to the best of my knowledge and belief, that all information declared in this form and all the documents attached to this form is true and correct. I also declare that, in submitting this form, I fully understand that Trade and Industry Department reserves at all times the right to release the above information and other information relates to this report, including particulars of the undersigned, to third parties for the purposes stated in Section 28(2) of the Chemical Weapons (Convention) Ordinance (Cap. 578).

Name of the operator (Note 2) for and on behalf of the above facility :
     	For official use only

Date of receipt :

Remarks :	
Signature of the operator and company chop :		
Date :