Request Form for Permit for a Quarry - Standards Institution of Israel

In accordance with (mark V): *

SI 3
SI 362-2
SI 1885
SI 1886

Request for (mark V): *

new permit
broadening the permit

English name of quarry: *

Location of quarry: *

Israel (Section A)
Abroad/Judea and Samaria (A/B/C areas)(Section B)

Hebrew name of quarry: *

Section A: for a quarry in Israel (within the green line borders)

Name of company with license for quarrying: *

Expiration date of license: *

Name on permit: *

Quarry owner
Quarry (not the owner)

Lot: *

Quarrying license number: *

Private company number *

Coordinates of quarry: *

Plot: *

Details of offices of company requesting permit

Address (street, number and city): *

Phone Number: *

Zip code: *

Fax number:

P.O. Box number

Email: *

Attached documents describing the quarry:

Valid quarry license *

Attach No file chosen

Location of quarry (coordinates) *

Attach No file chosen

Aerial photo of quarry (with quarrying borders) *

Attach No file chosen

Officers:

Name of General Manager

Phone Number - General Manager

Position

Name

Phone Number

Contact person with SII:

Contact Person with SII *

Email *

Position *

Phone Number *

Section B: For a quarry abroad or in Judea and Samaria (A/B/C areas)

Quarry owner: *

Private company number of quarry owner: *

Name on permit: *

Quarry owner
Quarry operator (if not the owner)

Quarry operator: *

Private company number of quarry operator: *

Coordinates of quarry: *

Details of offices of company requesting permit: Quarry owner/Quarry operator

Address (street, number and city): *

Phone Number: *

Zip code: *

Fax number:

P.O. Box number

Email: *

Officers:

Name of General manager of quarry operator

Name of Importer

Phone Number - General manager of quarry operator

Phone Number - Importer

Position

Name

Phone Number

Contact person with SII:

Contact Person with SII *

Email *

Position *

Phone Number *

For Sections A and B - Documents required

Owner's license of the quarry

Attach No file chosen

Approval by the quarry owner to perform an audit in the quarry area *

Attach No file chosen

Other documents

Attach No file chosen

Note: If the documents are provided to SII in a foreign language other than English or Hebrew, the documents shall be provided with notarized approval of their translation into Hebrew or English.

Confirmation by the quarry owner to operate the quarry *

Attach No file chosen

Confirmation of the quarry location (coordinates)

Attach No file chosen

Geological report

Attach No file chosen

Section C

If yes, we, the undersigned, request that the preliminary clarification agreement between us and SII on

Date *

shall apply also to the aforementioned product, and if the Licensing Committee approves the Standards Mark for the quarry, the supervision agreement signed with SII on

Date *

shall apply.

Details of the product:

Product name *

Product name in English

Product description *

List of all the models of the product *

Names of the models in English *

Are the products (or their parts) produced at other sites? *

No
Yes

We, the undersigned hereby request to allow us to mark the abovementioned product with the Standards Mark / Safety Mark. We undertake the following:

A. to conform to the Standards Law, 1953, and its Regulations and the conditions and arrangements established by the Standards Mark Directorate, and the resulting Licensing Committee.

B. to permit and assist the SII General Manager's representative to visit the plants and the location of assembly of the product, and other plants that produce the product or parts thereof or perform the assembly, and to conduct process tests there.

C. to allow and assist the SII General Manager's representative to take samples, free of charge, of the product and of the parts and materials used in their manufacture for the purpose of conducting preliminary examinations.

D. not to publicize in any manner whatsoever that the company or its products is or will be in the future, under SII supervision or is being examined or will be examined by them, until approval of the permit by SII.

E. to bear the expenses involved in handling this request.

Name *

signature *

Date *

Position *

Stamp (A file with a stamp must be attached) *

Attach No file chosen