2249.02; Attachment L - [DRAFT] FFDCA §408(p) Order for SDWA Chemicals - Initial Response Form for Individual Order Recipients (EPA Form No. tba) (Sept. 20, 2010).



## DRAFT UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, D.C. 20460

Endocrine Disruptor Screening Program (EDSP) FFDCA §408(p) Order - SDWA §1457 Substance OMB Control No. 2070-0176



### INITIAL RESPONSE FORM for INDI VIDUAL ORDER RECIPIENTS

Paperwork Reduction Act Notice: The public reporting burden for this collection of informat ion is estimated to average 1 hour per response. Send comments regarding the burden estimate to: Director, Collection St rategies Division (2822T), U.S. Environmental Protection Agen cy, Washington, DC 20460. Do not send the completed form to this address – follow the mailing instructions in the Order and Part 4 below. 

## PART 1 Recipient Information (From the Order and Completed by EPA):

1.1. Order Info: A. Order #: B. Date Issued: C. Initial Response Due:

1.2. Company Name: 1.3. Address:

1.4. Contact Person:

1.5. Chemical Info: A. CAS #: B. Chemical Name: C. Company #(s):



## PART 2 Recipient’s Initial Response: (Please refer to the Order for more inform ation about response options, as well as detailed instructions on how to comply with the Order.)


###  2.1. I will generate new data or am citing/submitting existing data. For each assay, check the appropriate box in the following table and follow the Order instructions to attach the data and/or re quired documentation. A. I will generate new data

. B. I am citing existing data and/or other scientifically relevant information

. C. I am submitting existing data and/or ot her scientifically relevant information

. D. I am entering (or offering to enter) into an agreement to form a Consortium to respond to the Order. The Consortium must provide a separate initial response within 150 calendar days from issuance of the Or der (see Initial Response Form for Consortium at http://www.epa.gov/endo/ .) Assays: A B C D Required documentation is attached. 2.1.1. Amphibian Metamorphosis (Frog)     2.1.2. Androgen Receptor Binding (Rat Prostate)     2.1.3. Aromatase (Human Recombinant)     2.1.4. Estrogen Receptor Binding     2.1.5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))     2.1.6. Fish Short-term Reproduction     2.1.7. Hershberger (Rat)     2.1.8. Female Pubertal (Rat)     2.1.9. Male Pubertal (Rat)     2.1.10. Steroidogenesis (Human Cell Line – H295R)     2.1.11. Uterotrophic (Rat)    


###  2.2. I am citing and/or submitting other scientifically-relevant information that I believe can be used to satisfy all of the Order. Required documentation is attached.


###  2.3. I am not subject to the Order. Required documentation is attached.


###  2.4. I do not, or will not continue, to manufacture or import this chemical. Required documentation is attached.



## PART 3 3.1. Certification. I certify that the statements made on this form and all attachments are true, accurate and complete. I acknowledge that any knowingly false or misleading statement may be punis hable by fine or imprisonment or both under applicable law. 3.2. Company’s Authorized Representative: Name and Title (Please Print or Type): Email address: Signature: 3.3. Date:

3.4. Phone Number:



## Part 4 Submit Completed Form Using One of these Methods: Mail To: Document Control Office (7407M), Office of Pollution Prev ention and Toxics (OPPT), U.S. EPA, 1200 Pennsylvania Ave. NW, Washington, D.C. 20460-0001. Deliver To: OPPT Document Control Office (DCO), EPA East Bldg., Rm. 6428, U.S. EPA, 1201 Constitution Ave. NW, Washington, D.C. 20004. [Deliveries are only accepted from 8:30 a.m. to 4 p.m., Monday through Friday, excluding legal holidays.] EPA Form No. 6300-05-SDWA