PARTIAL DECLARATION OF COMPLIANCE WITH SUSTAINABILITY CRITERIA 
according to the Part C Annex 4 Government Regulation No. 351/2012 on sustainability criteria for biofuels 
Unique identification number of the partial declaration:          
Issuer: 
       
	Recipient: 
     	Authorized person: 
        
	
1. Information about biomass/liquid or gaseous intermediate products for the production of biofuels:
Type, share:      
Quantity (t):      
Country of biomass origin:      
The biomass/liquid or gaseous intermediate products have been produced from waste or residues whit origin other than from agricultural, forestry, aquaculture, and fisheries. 
                                                                            yes                                    no 	
2. The greenhouse gas emissions production:
The greenhouse gas emissions production (gCO2ekv/kg or gCO2ekv/MJ) :                       
The greenhouse gas emissions production has been determined using:
 disaggregated default values laid down in Part C of Annex 1 or default value laid down in Part A of Annex 1 Government Regulation
  actual values calculated in accordance with the methodology laid down in Part B of     Annex 1 Government Regulation
  combination of actual values with disaggregated default value laid down in Part C of Annex 1 Government Regulation
  bonus for growing biomass on deteriorated land according to Point 7 of Part B Annex 1 Government Regulation has been used 
  bonus for using improved agricultural procedures according to Point 1 Part B Annex 1   Government Regulation has been used5
Transportation means and distance:     	

           
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  Place and date of issue                                                                                Signature