Shipper's Declaration Form - First Sequence

The following are the fields to be completed on the form (continued):

First Sequence - Dangerous Good Identification

• UN number or North American (NA) or Identification Number (ID) (Key 11) from Column 2 of Table A4.1. Be sure to include UN, ID, or NA as a prefix before the number. For a hazardous substance, enter the letters "RQ" (A4.4).
• Proper Shipping Name (Key 12), as determined according to Table A4.1. For certain PSNs, you must additionally enter:
• Technical name, in parentheses, if required by Attachment 4
• "TOXIC-INHALATION HAZARD" for materials that are poisonous when inhaled and "ZONE A", "ZONE B", "ZONE C", or "ZONE D" for gases; or "ZONE A" or "ZONE B" for liquids as appropriate. See Key 12 for more details.
• "WASTE" before the PSN for a hazardous material that is a classified as a hazardous waste.
• "EMPTY UNCLEANED" or "RESIDUE LAST CONTAINED" before or after the PSN for empty packagings containing residue of dangerous goods.
• Class or Division (Key 13), when assigned, of the hazardous material (from Column 4 of Table A4.1). For a single item with more than one hazard, enter the primary hazard's class number. For Class 1 materials, refer to Key 13 in the table for details.
• Subsidiary hazard class or division numbers from Column 6 (Key 14). Enter any subsidiary hazard class or division number. Or, you can enter this information following the primary Class or Division hazard (Key 13), in parentheses. If you include the subsidiary hazard class division in parentheses after the primary class or division in Key 13, you do not need to include them in Key 14. Example: UN 2744, Cyclobutyl chloroformate, 6.1, (8, 3), PG II. Subsidiary hazards can be identified by sources other than Table A4.1, such as an SDS. In these cases, annotate the source in Key 19; example "Subsidiary Hazard Assigned Per SDS."
• PG (Packing Group) I, II or III (Key 15) is the applicable packing group for the dangerous good (from Column 5 of Table A4.1).

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