# Appendix A Please read Privacy Act Statement and instructions on reverse before completing this form.

United States Environmental Protection Agency Washington, DC 20460 

# TSCA CBI Access Request, Agreement, and Approval

Section I.

– Access Request

1. Na me (Last, First, MI) 2. 9

- Digit ID Number (e.g., SSN) 3. Telephone Number

4. Requestor (Agency/Office/Division/Branch) 5. Document Control Officer (DCO) 6. DCO Telephone Number

7.TSCA Sections for which access is

required. Check all that apply. Use b lank ALL _____

- OR

- 4 ___ 5 ___ 6 ___ 8 ___ 12 ___ 13 ___ 21 ___ _________

space to request other sections not listed.

8. Justification for TSCA CBI access. Other
Select appropriate code from instructions on List Justification on reverse side
reverse side. (Check one for all that apply). A ______ B ______ C ______ D

______ 

## Section II.

– Contract Information



# - Contractor Employees Only

9. Employer’s Name 10a. Employer’s Address 10b. City 10c. ST 10d. Zipcode

11. Contract Number 12. EPA Project Officer 13. EP A Project Officer Telephone



## Section III.

– OPPT Secure Storage Area Access

– HQ Federal and HQ Contractor Employees Only

14. Check if EPA ID Badge. Badge is required.

Yes (New) Need Replacement No (List Present EPA ID Badge Number ___________________________)

15. List OPPT Restricted are as by Division to which physical access is required.

Home Division (24 hour access) Other Divisions (6A.M.

– 6P.M. only) Access to CBIC Only IMD (DCO and IMD Computer Rms.)

16. List OPPT areas by Division and Room Number for which Alarm Activation/Deact ivation Authority is requested.



## Section IV.

– Confidentiality Agreement

I understand that I will have access to certain Confidential Business Information submitted under the Toxic Substances Control Act (TSCA, 15 USC 2601 et seq.). This access has been granted in accordance with my official duties relating to Environmental Protection Agency programs.

I understand that TSCA CBI may be used only in connection with my official duties and may not be disclosed except as authorized by TSCA and Agency regula tions. I have received a copy of, and understand the procedures set forth in, the TSCA CBI Protection Manual. I agree that I will treat any TSCA CBI furnished to me as confidential and that I will follow these procedures.

I understand that under section 1 4(d) of TSCA (15 USC 2513(d)), I am liable for a possible fine of up to $5,000 and/or imprisonment for up to one year if I willfully disclose TSCA CBI to any person not authorized to receive it. In addition, I understand that I may be subject to disciplina ry action for violation of this agreement with penalties ranging up to and including dismissal.

I understand that my obligation to protect TSCA CBI, which has been disclosed to me as part of my official job duties, continues after either termination of m y assignment or termination of my employment.

I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law.

17. Signature of Employee 18. Date



## Section V.

– Requesting Official Approval

20. Name and Signature of Requesting Official. (Immediate Supervisor

– EPA Project Office r for Contractors) As the immediate supervisor of (or the EPA Project Officer for) the above mentioned employee, I certify he/she has successfully completed a TSCA CBI Security Briefing on the date shown. 19. TSCA CBI Security Briefing Date

Name Signature 21. Date

22. Date Received 23. Approved (TSCA Security Official Signature) 24. Approval Date

DCO Code Barcode Status Code Alarm Zones Data Entry Date and Initials

1. 2. 

## EPA Form 7740

- 6 (Rev. 10- 03). Replaces previous version of 7740

- 6 and 7740

- 6A.

## Paperwork Reduction Act Notice

The public reporting burden for the collection of information is estimated to average .84 hours per response. This estimate i ncludes time for reviewing instructions, gathering and maintaining the needed data, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information to the Director, Collection Strategies Division, US Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington DC 20460, and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503, ma r ked ATTENTION: Desk Officer for EPA. Include the OMB No. identified on page 1 in any

correspondence. Do not send the completed form to this address. Submit the form in accordance with the instructions in the CBI Manual. 

## Privacy Act Statement

Furnishing your Social Security Number is voluntary, but encouraged. The information on this form is used by EPA to maintain a record of those persons cleared for access to T SCA Confidential Business Information (CBI) and to maintain the security of TSCA CBI.

Disclosure of information from this form may be made to the Office of Pollution Prevention and Toxics (OPPT) contractors in order to carry out
functions for E PA compatible with the purpose for which this information is collected; to other Federal agencies when they possess TSCA CBI and need to verify clearance to EPA and EPA contractor employees for access; to the Department of Justice when related to litigati o n or anticipated litigation involving the records or the subject matter of the records; to the appropriate Federal, State or local agency charged with enforcing a statute or regulation, violation of which is indicated by a record in this system; where nec e ssary, to a State, Federal or local agency maintaining information pertinent to hiring, retention, or clearance of an employee, letting of a contract, or issuance of a grant or other magistrate or administrative tribunal; in the course of litigation under TSCA; and to a member of Congress acting on behalf of an individual to whom records in this system pertain.



## Instructions for Form Completion
Section I

– To be completed by all Section III

– To be completed by HQ Federal and HQ Contractor employees only

1. List Full Name 2. List 9

- Digit ID (e.g., SSN) 3. List Telephone number of person in item 1 4. List Full Acronym of Requesting Office (i.e. EPA Office in which the individual works or for contractor employees, the EPA Office with whom
the contract is w ith)
5. List the immediate Document Control Officer for the office in which the

individual works 6. List the telephone number of the Document Control Officer 7. Check the TSCA Sections for which access is requested or check ALL if applicable
8. Circle the appropriate Access Justification Code

A

. Employee is an EPA employee or EPA contractor employee whose work assignments involve the New and/or Existing Chemical Programs of
TSCA. Hence access to the TSCA sections listed in item 7 of this form is required in performance of his/her duties

.

B

. Employee is an EPA employee or EPA contractor employee whose work entails the administration of computer systems housing TSCA CBI.
Hence access to the TSCA sections listed in item 7 of this form is required

. C

. Empl oyee is an EPA employee or EPA contractor employee whose work entails physical security or maintenance for TSCA CBI secure storage areas. Although employee will not actually work with any TSCA CBI materials, access to the TSCA sections listed in
item 7 of this form is required

. D . List Justification here NOTE: These procedures apply only to employees requiring access to OPPT Secure Storage areas. All others follow standard Agency procedures. 14. Check either box a, b, c or (c&d) f or EPA ID badge or Contractor Building Pass. If box c is checked, write in badge number.
a. Yes

- Check if new employee getting first EPA ID Badge. (New programmed badge and barcode) b. Need Replacement

- Check if replacement ID Badge is needed (replacemen t badge and barcode)

c. No

- Existing badge needs programming. List ID Badge no. 15. Check and list OPPT secured areas for which access (via “RUSCO” electronic door control system) is required. List Division acronyms for the requested areas.
Home Division

- List Division in which employee works
Other Divisions

- List other OPPT Divisions for which unrestricted daytime access is requested CBIC Only

- To be checked for those who only need to access the
Confidential Business Information Center.

IMD Areas

- Emp loyees who need to regularly access the IMD Document
Control Office Suite should circle DC0 in the fourth block. Only IMD staff and contractors who work in IMD computer rooms should circle IMD Computer Rooms

. 16. List OPPT areas by Division and Room number s for which Alarm Activation/Deactivation authority is requested. Generally, this is employees home Division only.



## Section II

– To be completed by Contractor Employees only Section IV

– To be completed by all

17. Employee Signature (must be original) 18. Signature Date 

## Section V

– To be completed by all

19. Enter date employee attended T SCA CBI Security Briefing 20. Immediate Supervisor/EPA Project Officers name and sign. 21. Date of signature 

## Section VI

– To be completed by OPPT Security 9. List Employer’s name

10a

- d. List Employe r’s address 11. List Contract number 12. List EPA Project Officer’s name 13. List EPA Project Officer’s telephone number