97727210441

1. Products consigned from (Exporter's business name, address, country) Reference No. 0002342/KBM/2020
PT POLYMER RESOURCES INDONESIA
JALAN RAYA PELABUHAN, CPO KABIL,NONGSA,KOTA BATAM 29467 ASEAN-CHINA FREE TRADE AREA
INDONESIA PREFERENTIAL TARIFF
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
TIANJIN ZHAO HENG GOODS & MATERIAL [Link]
NO. 75 YUEJIN ROAD (ROOM 312 DISTRICT WORKERS CLUB),
DONGLI DISTRICT, TIANJIN Issued in INDONESIA
TEL:0086-22-84957440
CHINA
See Overleaf Notes

3. Means of transport and route (as far as known) 4. For Official use

Departure Date APRIL 18, 2020 Preferential Treatment Given

Vessel's name/Aircraft etc. CAPRICORN 59/RB062 Preferential Treatment Not Given (Please state reason/s)

.................................................................................................................
Port of Discharge TIANJINXINGANG
Signature of Authorised Signatory of the Importing Party

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number,
number numbers of description of products (including (see Overleaf or net weight or date of invoices
packages quantity where appropriate and Notes) other quantity and
HS number in six digit code) value (FOB) only
when RVC
criterion is applied

1 TCLU5411321(40'H LLDPE RECYCLED PELLET:40 BALES 100% 26,000.00 KGS PRI-CN0410

C)/ML-ID2936602 HS: 3901.40.20 USD 13,780.00 APRIL 15, 2020
2 MSKU8321039(40' LLDPE RECYCLED PELLET:40 BALES 100% 26,000.00 KGS PRI-CN0410
HC)/ML-ID2936601 HS: 3901.40.20 USD 13,780.00 APRIL 15, 2020
3 MRKU5132343(40' LLDPE RECYCLED PELLET:40 BALES 100% 26,000.00 KGS PRI-CN0410
HC)/ML-ID2936603 HS: 3901.40.20 USD 13,780.00 APRIL 15, 2020

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement are It is hereby certified, on the basis of control carried out, that the declaration by
correct; that all the products were produced in the exporter is correct

INDONESIA ISSUING OFFICE IN KOTA BATAM

.....................................................................
(Country)

and that they comply with the origin requirements specified for these
products in the Rules of Origin for the ACFTA for the products exported to

CHINA
.....................................................................
(Importing Country)

INDONESIA, APRIL 20, 2020

..........................................................................................................
Place and date, signature of authorised signatory

LENY NURISKAWATY
13.
v
Issued Retroactively Exhibition BATAM, APRIL 20, 2020
.............................................................................................................
Movement Certificate Third Party Invoicing Place and date, signature and stamp of certifying authority

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