FORM 402(SEE RULE 51) ORIGINAL Declearation under section 68 of the gujarat value added tax act 2003 DUPLICATE

(For movement of within the state or goods moving outside hte state) TRIPLICATE To,

The officer in charge Check post .............

(1) Place fom which goods are dispatched BARDOLI District SURAT(2) Place to which goods are dispatched JIGANI District(3) Details of goods invoice No 030 Date 11/06/2011(4) Consignor’s details:

Name SURANA ABRASIVE PVT. LTD. State GUJARATAddress SURVEY 290/8,BLOCK NO 296, NEAR GEB, Registraction certificate No 24224001316

NH-6,BARDOLI-SURAT ROAD., BARDOLI. Date 17/02/2011Telephone +91 2622 226760 CST registration No 24724001316Fax No Date 01/03/2011

(5) Nature of Trancation :(a) Inter state sale (b) Transfer of docoument of title (c) Depot Transfer (d) Consignment to Branch/Agent (e) For job works/Works contract (e) For export (f) Any Other

(6) Consignee’s details:Name SURANA ABRASIVE PVT. LTD. State KARNATAKAAddress W-55, 1TH MAIN ROAD, 4TH CROSS, Registraction certificate No 29740613615

B.R.AMBEDKAR INDL, ESTATE,1ST PHASE, JIGANI, ANEKAL TALUK Date 24/05/2011

Telephone +91 8880145807 CST registration No 29740613615Fax No Date 24/05/2011

Consigned Value RsSr No.

Descripation of Goods Commodity Code

Unit Quantity Rate of Tax Value

1 WATER CHEMICAL - 10 BARREL - 75000.0023

(7) Transporter’s Details : (a) Name LALJI MULJI TRANSPORT CO.(b) Address -------------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------------(C) Owner/Partner’s Name -------------------------------------------------------------------------------

(8) Vehicle No ------------------------------- L.R. No 5306191. Date 11/06/2011(9) Driver’s Details (a) ---------------------------------------------------------------------------------------------------------------------------

(b) Address -------------------------------------------------------------------------------------------------------------------------(c) Driving Licence No. ----------------------------------------------------------------------------------------------------------(d) Licence issuing state --------------------------------------------------------------------------------------------------------(e) Driver’s Signature ------------------------------------------------------------------------------------------------------------

(10) Name and the address of person in charge of goods -------------------------------------------------------------------------------

Place : BARDOLI Signature With seal :

Date : 11/06/2011 Designation :

For commercial Tax Department/Check postEntry No. Reason of abnormal

stoppageResult if any

Vehicale Date TimeArrivalDepart

Date ----------------------------- Signature ---------------------------------------------- Designation -----------------------------------

y