Trade and Industry Department
Government of the Hong Kong Special Administrative Region
Chemical Weapons (Convention) Ordinance (Cap. 578)		
ANNUAL REPORT on SCHEDULE 3 CHEMICALS –
PAST Activities AT Each Plant of a FacilitY DURING THE PREVIOUS YEAR (Form S3-1)	
Part A : Details of the facility (Note 1)	
1.	Facility name :
     	5.	Facility address :
	     
	     
	     	
2.	Name of the owner, company or enterprise operating the above facility :
     		
(Please mark ‘X’ in one of the following and provide details) :
 HKID no.  Passport no.  BR no.:        	
 other relevant registration no. (please specify) :      	

	Tel no. :      	Fax no. :      	
3.	Permit number :
     	4.	Year of past activities reported in this form 
(i.e. the "reporting year", must be a calendar year) : 
     	6.	No. of declared Schedule 3 plants in the above facility :      

	No. of declared Schedule 2 plants in the above facility :      	
Part B : Details of each Schedule 3 plant of the facility (Please use additional Form S3-1 if necessary)	
1.	Name of the Schedule 3 plant :
     	3.	The main activities (Note 5) of the plant in relation to Schedule 3 chemicals :
	(Please mark ‘X’ if applicable)
	 Production	 Storage
	 Processing	 Re-packaging
	 Consumption	 Research and development	
Precise location, including specific building or structure no. (if any), of the above plant :      		
2.	Name of the owner, company or enterprise operating the above plant :
     	4.	Use Product Group Codes to describe the main activities of the plant 
(Note 6) :      
			
(Please mark ‘X’ in one of the following and provide details) :
 HKID no.  Passport no.  BR no.:        	
 other relevant registration no. (please specify) :       	5. 	This plant produced Schedule 1 chemicals as an unavoidable by-product in an amount exceeding 3% of the total product or produced any other chemicals that can be used for chemical weapons purposes:
		Yes		No  (please mark ‘X’)		
Part C : Details of each Schedule 3 chemical at the plant (Please use additional Form S3-1 if necessary)	
1. IUPAC chemical name (Note 3) :
     	5. Any production (Note 5) of the chemical in the reporting year :
	 Yes	 No  (please mark ‘X’)	
2. CAS registry no. (Note 4) :      	If yes, please indicate quantity in tonnes produced in the reporting year :	
3. Common name or trade name :      	        	 tonnes	
4. Structural formula :
       	6. The purpose(s) for which this chemical was produced :
(Please mark ‘X’ if applicable)
 In-line consumption as produced (captive use) 
 Synthetic intermediate stored and/or used on site
 Transfer to other industry
 Others (please specify) :      	
Part D : Total number of Form S3-1 submitted (including this page) :        	 pages	
Part E : Undertaking by the permit holder	
I, the undersigned, hereby declare to the best of my knowledge and belief, that all information provided in this form and in any additional pages 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 any information relates to this report, including particulars of the undersigned, to third parties for purposes stated in Section 28(2) of the Chemical Weapons (Convention) Ordinance (Cap. 578).

Name of the permit holder of the facility :      

Signature of the permit holder and company chop :

Date :      	For official use only

Date of receipt : 

Remarks :