r-------·~----'1--~~-----------------------------------------------------------------------------------------------------. 

' r---~u·-.s~.-EN-V--IR_O_N_M_E_N_T_A_L--PR_O_T_E_C_T_I_O_N_A_G_E_N_C_Y ____ ~--------A-G_E_N_C_Y_U_S_E __ O_N_L_Y ______ ~ 

&EPA PREMANUFACTURE Date ofrecei t 

NOTICE 

FOR NFWf'HFMTf'AT. ~TTH~TANC'P~ 

lllllllllllilllllllllllllli IIIII IIIII IIIIi IIIIi l!il! IIIII Iii I i li 1!111 :11111 

)N 

5 I 0 8 0 0 0 0 5 I 2 I ~ 

Enter the total number of pages 

in the Premanufacture Notice 

Part I GENERAL INFORMATION 

You must provide the currently correct Chemical Abstracts (CA) Name of the new 

chemical substance, even ifyou claim the identity as confidentiaL You may authorize 

another person to submit chemical identity information for you, but your submission 

will not be complete and the review will not begin until EPA receives this 

information. A letter in support of your submission should reference your TS user tee 

identification number. You must submit an original and two copies of this notice 

including all test data. If you claimed any information as confidential, a single 

sanitized copy must also be submitted. 

Part II HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE 

If there are several manufacture, processing, or use operations to be described in Part 

II, sections A and B of this notice, reproduce the sections as needed. 

Part III LIST OF ATTACHMENTS 

Attach additional sheets ifthere is not enough space to answer a question fully. Label 

each continuation sheet with the corresponding section heading. In Part III, list these 

attachments, any test data or other data and any optional information included in the 

notice. 

OPTIONAL INFORMATION 

You may include any information that you want EPA to consider in evaluating the 

new substance. On page 11 of this form, space has been provided for you to describe 

pollution prevention and recycling information you may have regarding the new 

substance. 

So-called "binding" boxes are included throughout this form for you to indicate your 

willingness to be bound to certain statements you make in this section, such as use, 

production volume, protective equipment ... This option is intended to reduce delays 

that routinely accompany the development of consent orders or Significant New Use 

Rules. Except in the case of exemption applications (such as TMEA, L VE, LOREX) 

where certain information provided in such notification is binding on the submitter 

when the Agency approves the exemption application, checking a binding box in this 

notice does not by itself prohibit the submitter from later deviating from the 

information (except chemical identity) reported in the form. 

CONFIDENTIALITY CLAIMS 

You may claim any information in this notice as confidentiaL To assert a claim on the 

form, mark (X) the confidential box next to the information that you claim as 

confidentiaL To assert a claim in an attachment, circle or bracket the information you 

claim as confidential. If you claim information in the notices as confidential, you must 

also provide a sanitized version of the notice, (including attachments). For additional 

instructions on claiming information as confidential, read the Instructions Manual. 

OMark (x) if any information in this notice is claimed as confidential. 

Page 

i' 

TEST DATA AND OTHER DATA 

You are required to submit all test data in your possession or control and to provide a 

description of all other data known to or reasonably ascertainable by you, if these data 

are related to the health and environmental effects on the manufacture, processing, 

distribution in commerce, use, or disposal of the new chemical substance. Standard 

literature citations may be submitted for data in the open scientific literature. 

Complete test data (written in English), not summaries of data. must be submitted if 

they do not appear in the open literature. You should clearly identifY whether test data 

is on the substance or on an analog. Also, the chemical composition of the tested 

material should be characterized. Following are examples of test data and other data. 

Data should be submitted according to the requirements of §720.50 of the 

Premanufacture Notification Rule (40 CFR Part 720). 

Test Data (Check Below any included in this notice) 

• Environmental fate data Oves •Other data Oves 

• Health effects data Oves Risk assessments 

• Environmental effects data DYes Structure/activity relationships 

• Physical/Chemical Properties* ~Yes Test data not in the possession or 

control of the submitter 

*A physical and chemical properties worksheet is located on the last page of this 

form. 

TYPE OF NOTICE (Check Only One) 

0PMN (Premanufacture Notice) 

1:8JINTERMEDIATE PMN (submitted in sequence with final product PMN) 

OsNUN (Significant New Use Notice) 

0TMEA (Test Marketing Exemption Application) 

0LVE (Low Volume Exemption)@ 40 CFR 723.50(c)(1) 

0LOREX (Low Release/Low Exposure Exemption)@ 40 CFR 723.50(c)(2) 

OL VE Modification 0LOREX Modification 

IS THIS A CONSOLIDATED PMN? Oves 

# of chemicals or polymers __ __ 

(Prenotice Communication# required, enter# on page 3) 

1 

I 

\ 
Public reporting burden for this collection of information is estimated to average II 0 hours per response, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments 

regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Director, Collection 

Strategies Division (2822), U.S. Environmental Protection Agency, I200 Pennsylvania Ave., N.W., Washington, D.C. 20460; and to the Office of 

Management and Budget, Paperwork Reduction Act (2070-00I2), Washington, D.C. 20503. 

CERTIFICATION 

I certify that to the best of my knowledge and belief: 

1. The company named in Part I, section A, subsection 1 a of this notice form intends to manufacture or import for a commercial 

purpose, other than in small quantities solely for research and development, the substance identified in Part I, Section B. 

2. All information provided in this notice is complete and truthful as of the date of submission. 

3. I am submitting with this notice all test data in my possession or control and a description of all other data known to or reasonably 

ascertainable by me as required by §720.50 of the Premanufacture Notification Rule. 

Additional Certification Statements: 

D If you are submitting a PMN, Intermediate PMN, Consolidated PMN, or SNUN, check the following user fee certification 

statement that applies: 

D The Company named in Part I, Secti~n A has remitted the fee of$2500 specified in 40 CFR 700.45(b), or 

~ The Company named in Part I, Section A has remitted the fee of$1000 for an Intermediate PMN (defined@ 40 CFR 700.43) in 

accordance with 40 CFR 700.45(b), or 

D The Company named in Part I Section A is a small business concern under 40 CFR 700.43 and has remitted a fee of$100 in 

accordance with 40 CFR 700.45(b). 

If you are submitting a low volume exemption (LVE) application in accordance with 40 CFR 723.50(c)(l) or a Low release 

and low exposure exemption (LoRex) application in accordance with 40 CFR 723.50(c)(2), check the following certification 

statements: 

D The manufacturer submitting this notice intends to manufacture or import the new chemical substance for commercial purposes, 

other than in small quantities solely for research and development, under the terms of 40 CFR 723.50. 

D The manufacturer is familiar with the terms of this section and will comply with those terms; and 

D The new chemical substance for which the notice is submitted meets all applicable exemption conditions. 

D Ifthis application is for an LYE in accordance with 40 CFR 723.50(c)(1), the manufacturer intends to commence manufacture of 

the exempted substance for commercial purposes within 1 year of the date of the expiration of the 30 day review period. 

The accuracy of the statements you make in this notice should reflect your best prediction of the anticipated facts regarding the chemical 

substance described herein. Any knowing and willful misinterpretation is subject to criminal penalty pursuant to 18 USC 1001. 

Signature and title of Authorized Official (Original Signature Required) Date 

Signature of agent (if applicable) Date 

Page 

Confidential 

X 

2 
Ia. Person 

Submittin 

g Notice 

(in U.S.) 

b. Agent (if 

applicabl 

e) 

c. Ifyou are submitting this notice as part of a joint submission, mark (X) this box.--------------. 

Joint Name of authorized official Position 

Submitter (if applicable) 1-c-=-om-p-an_y __________________ ..J...._ _______________ _ 

Mailing address (number and street) 

2. Technical 

Contact 

(in U.S.) 

3. If you have had a prenotice communication (PC) concerning this notice 

and EPA assigned a PC Number to the notice, enter the number. 

4. If you previously submitted an exemption application for the chemical 

substance covered by this notice, enter the exemption number assigned 

by EPA. If you previously submitted a PMN for this substance enter the 

PMN number assigned by EPA (i.e. withdrawn or incomplete). 

5. If you have submitted a notice of Bona fide intent to manufacture or 

import for the chemical substance covered by this notice, enter the 

notice number assigned by EPA. 

1. Manufacture 

Only 

6. Type of Notice- Mark (X) D Binding 

Option Mark 

Page 

Mark(X) 

- if none ... • 

- Mark(X) • ... if none 

-

Mark (X) ... • if none 

Import 

Only 

D Binding 3. 0Both 

Option 

Mark 

Contidential 

~ 

~ 

~ 

3 
Section B- CHEMICAL IDENTITY INFORMATION: You must provide a currently correct Chemical Abstracts (CA) name ofthe substance 

based on the ninth Collective Index (9CI) ofCA nomenclature rules and conventions. 

the "Confidential" box next to item 

1. Class 1 or 2 chemical substances (for definitions of class 1 and class 2 substances, see the Instructions Manual) 

a. Class of substance - Mark (X) 1 II Class 1 or 211 Class 2 

b. Chemical name (Currently correct Chemical Abstracts (CA) Name that is consistent with TSCA Inventory listings for 

similar substances. For Class 1 substances a CA Index Name must be provided. For Class 2 substances either a CA Index 

Name or CA Preferred Name must be provided, whichever is appropriate based on CA 9CI nomenclature rules and 

c. Please identify which method you used to develop or obtain the specified identity information reported in this notice: 

(check one) 

~Method 1 (CAS Inventory Expert Service- a copy of the Identification D Method 2 (Other Source) 

report obtained from the CAS Inventory Expert Service must be 

submitted as an attachment to this notice) 

d. Molecular formula and CAS Number (if a number already exists for the substance) 

CAS# 

e. For a class 1 substance, provide a complete and correct chemical 

-

structure diagram. For a class 2 substance- (1) List the 

immediate precursor substances with their respective CAS Registry Numbers. (2) Describe the nature of the reaction or 

process. (3) Indicate the range of composition and the typical composition (where appropriate). (4) Provide a correct 

chemical structure as can be known, if one can be reasonably ascertained. 

Page 

Confidential 

X 

X 

X 

X 

4 
..--·-- UL. 2. 2008- 2: 10P~ NO. 091-P. 

Soct.ion 8-CHEMICAL IDENTITY INFORMATION-Contin'll.ed 

(for a ofpolymer, see 

of the lowest molecular weight you .,........,........,. of low molecular weight species (not inclwling residual monomers, reaetants, or 

c. Please wbich you used to develop or obtain the 

notice. (check one) 

• Method 1 (CAS Inventory Expert Service- a copy of the identification report 

obtained from CAS Inventocy Expert Sel"Vice must be submitted as an attachment 

to 

as c:an be known, one can be reasonably 

TS·WN08AP Page 5 
Section B- CHEMICAL IDENTITY INFORMATION- Continued 

3. Impurities 

(a)- Identify each impurity that may be reasonably anticipat~d to be present in the chemical substance as manufactured for commercial purposes. 

Provide the CAS Registry Number if available. If there are unidentified impurities enter "unidentified." 

(b) -Estimate the maximum weight % of each impurity. Ifthere are unidentified impurities, estimate their total weight %. 

Impurity and CAS Registry Number 

(a) 

attach a continuation sheet. 

4. Synonyms- Enter any chemical synonyms for the new chemical substance identified in subsection I or 2. 

attach a continuation sheet. 

attach a continuation sheet. 

Maximum 

percent 

% 

% 

% 

% 

% 

Confidential 

D 

6. Generic chemical name- if you claim chemical identity as confidential, you must provide a generic chemical name for your substance 

that reveals the specific chemical identity of the new chemical substance to the maximum extent possible. Refer 

to the TSCA Chemical Substance Inventory, 1985 Edition, Appendix B for guidance on developing generic 

names. 

Alcohol propoxylate 

D Mark (X) this box if you attach a continuation sheet. 

7. Byproducts- Describe any byproducts resulting from the manufacture, processing, use or disposal of the new chemical substance. 

Provide the CAS Number if available. 

Mark (X) this box if you attach a continuation sheet. 

Page 

Confidential 

6 
Part I GENERAl INFORMATION -Continued 

~ Section C- CHEMICAL IDENTITY INFORMATION- Continued 

Ma}"~(X) the "Confidential" box next to any item you claim as confidential. 

1. Production volume- Estimate the maximum production volume during the first 12 months of production. Also estimate the maximum 

production volume for any consecutive 12-month period during the first three years of production. Estimates should be on 100% new 

chemical substance basis. For a low volume Exemption application, if you choose to have your notice reviewed at a lower production 

volume than 10,000 kglyr, specify the volume and mark (x) in the box. If 6• w ... ~w, you are bound to this volume. 

Maximum first 12-month production (kg/yr) Maximum 12-month production (kg/yr) Conti- Binding 

Option (1 00% new chemical substance basis) ( 1 00% new chemical substance basis) dential Mark (x) 

-- ~ [ 

2. Use Information- You must make separate confidentiality claims for the description of the category of use, the percent of production 

volume devoted to each category, the formulation of the new substance, and other use information. Mark (X) the "Confidential" Box next 

to any item you claim as confidential. 

a. (1)- Describe each intended category of use of the new chemical substance by function and application. 

(2)- Mark (X) this column if entry in column (1) is confidential business information (CBI). 

(3)- Indicate your willingness to have the information provided in column (1) binding. 

(4)- Estimate the percent of total production for the first three years devoted to each category of use. 

(5)- Mark (X) this column if entry in column (4) is confidential business information (CBI) 

(6)- Estimate the percent of the new substance as formulated in mixtures, suspensions, emulsions, solutions, or gels 

as manufactured for commercial purposes at sites under your control associated with each category of use. 

(7)- Mark (X) this column if entry in column (6) is confidential business information (CBI) 

(8) - Indicate % of product volume expected for the listed "use" sectors. Mark more than one box if appropriate. Mark 

(X) to indicate your willingness to have the use type provided in (8) binding. 

(9)- Mark (X) this column if entry(ies) in column (8) is (are) confidential business information (CBI) 

Category of use (I) Binding Produc- %in % of substance expected per use (by function and application i.e. a dispersive dye CBI Option CBI Form- CBI CBI 

for "'· polyester fibers) IMark(x) tion% ulation (8) 

(I) (2) (3) (4) (5) (6) (7) Site- Con-* Indus- Com-

~~~~~; (9) limited sumer trial mercia! 

~ D .% ~ .% ~ • ~ 

% % 

% % 

% % 

% % 

% % 

=:J. % % 

*If you have identified a "consumer" use, please provide on a continuation sheet a detailed description of the use(s) of this chemical 

substance in consumer products. In addition include estimates of the concentration of the new chemical substance as expected in consumer 

products and describe the chemical reactions by which this substance loses its identity in the consumer product. 

D Mark (X) this box if you attach a continuation sheet. 

b. Generic If you claim any category of use description in subsection 2a as confidential, enter a generic description of that category. 

use Read the Instructions Manual for examples of generic use descriptions. 

description Chemical intermediate 

D Mark (X) this box if you attach a continuation sheet. 

3. Hazard Information- Include in the notice a copy of reasonable facsimile of any hazard warning statement, label, material safety Binding 

data sheet, or other information which will be provided to any person who is reasonably likely to be exposed to this substance Option 

regarding protective equipment or practices for the safe handling, transport, use, or disposal of the new substance. List in part III Mark 

hazard information you include. (x) 

D Mark (X) this box if you attach a continuation sheet. D 

Page 7 
Part II- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE 

• Mark (X) the "Confidential" box next 

Section A- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER to any item you claim as confidential. 

Complete section A for each type of manufacture, processing, or use operation involving the new chemical substance at industrial sites you 

control. Importers do not have to complete this section for operations outside the U.S.; however, you may still have reporting requirements if 

there are further industrial or use after You must describe these · See Instructions manual. 

1. 

of the site at which the will occur. 

If the same operation will occur at more than one site, enter the number of sites. Identify 

the additional sites on a continuation sheet, and if any of the sites have significantly 

different production rates or operations, include all the information requested in this 

section for those sites as attachments. 

1. Batch 

2. Continuous 

Use 

Batches/year 

Confidential 

d. Process description Mark (X) to indicate your willingness to have your process description binding. 

(1) Diagram the major unit operation steps and chemical conversions. Include interim storage and transport containers (specity-e.g. 5 

gallon pails, 55 gallon drum, rail car, tank truck, etc.). 

(2) Provide the identity, the approximate weight (by kg/day or kg/batch on an 100% new chemical substance basis), and entry point of all 

starting materials and feedstocks (including reactants, solvents, and catalysts, etc.), and of all products, recycle streams, and wastes. 

Include cleaning chemicals (note frequency if not used daily or per batch). 

Identify by number the points of release, including small or intermittent releases, to the environment of the new chemical substance. 

~ Mark (X) this box if you attach a continuation sheet. 

Page 8 
TS#WN08AP , 

Submitter'-

Continuation sheet for 1 d (process description): 

Page 9 
Part II- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE 

• Mark (X) the "Confidential" box next 

SectiOn A- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER to any item you claim as confidential. 

Complete section A for each type of manufacture, processing, or use operation involving the new chemical substance at industrial sites you 

control. Importers do not have to complete this section for operations outside the U.S.; however, you may still have reporting requirements if 

there are further industrial · or use · after · You must describe these See Instructions manual. 

1. 

Ifthe same operation will occur at more than one site, enter the number of sites. Identify 

the additional sites on a continuation sheet, and if any of the sites have significantly 

different production rates or operations, include all the information requested in this 

section for those sites as attachments. 

1. Batch 

2. Continuous 

Use 

Batches/year 

Confidential 

d. Process description Mark (X) to indicate your willingness to have your process description binding. 

(3) Diagram the major unit operation steps and chemical conversions. Include interim storage and transport containers (specity-e.g. 5 

gallon pails, 55 gallon drum, rail car, tank truck, etc.). 

(4) Provide the identity, the approximate weight (by kg/day or kg/batch on an 100% new chemical substance basis), and entry point of all 

starting materials and feedstocks (including reactants, solvents, and catalysts, etc.), and of all products, recycle streams, and wastes. 

Include cleaning chemicals (note frequency if not used daily or per batch). 

Identify by number the points of release, including small or intermittent releases, to the environment of the new chemical substance. 

I:8J Mark (X) this box if you attach a continuation sheet. 

Page 10 
TS#WN08AP . 

Submitter!_ 

Continuation sheet for ld (process description): 

Page 11 
Section A- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER-- Continued 

Occupational Exposure- You must make separate confidentiality claims for the description of worker activity, physical form of the new 

chemical substance, number of workers exposed, and duration of activity. Mark (X) the "Confidential" box next to any item you claim as 

confidential. 

(1)- Describe the activities (e.g. bag dumping, tote filling, unloading drums, sampling, cleaning, etc.) in which workers may be exposed to 

the substance. 

(2)- Mark (X) this column if entry in column (1) is confidential business information (CBI). 

(3)- Describe any protective equipment and engineering controls used to protect workers. 

(4)- and (6)- Indicate your willingness to have the information provided in column (3) or (5) binding. 

(5)- Indicate the physical form(s) of the new chemical substance (e.g. solid: crystal, granule, powder, or dust) and% new chemical 

substance (if part of a mixture) at the time of exposure. 

(7)- Mark (X) this column if entry in column (5) is confidential business information (CBI). 

(8)- Estimate the maximum number of workers involved in each activity for all sites combined. 

(9)- Mark (X) this column if entry in column (8) is confidential business information (CBI). 

(10) and (11)- Estimate the maximum duration of the activity for any worker in hours per day and days per year. 

-Mark this column if entries in columns and are confidential business information 

CBI 

D D I 

D D I 

D D I 

D D D D D 

D D D D D 

I • 

I • 

I • 

Environmental Release and - You must make separate confidentiality claims for the release number and the amount of the new 

chemical substance released and other release and disposal information. Mark (X) the "Confidential" box next to each item you claim as 

confidential. 

( 1) - Enter the number of each release point identified in the process description, part II, section A, subsection 1 d(3). 

(2)- Estimate the amount of the new substance released (a) directly to the environment or (b) into control technology (in kg/day or 

kg/batch). 

(3)- Mark (X) this column if entries in columns (1) and (2) are confidential business information (CBI). 

(4)- Identify the media of release i.e. stack air, fugitive air (optional-see Instruction Manual), surface water, on-site or off-site land or 

incineration, POTW, or other (please specify) to which the new substance will be released from that release point. 

D 

D 

(5)- a. Describe control technology, if any, and control efficiency that will be used to limit the release of the new substance to the 

environment. For releases disposed of on land, characterize the disposal method and state whether it is approved for disposal of 

RCRA hazardous waste. On a continuation sheet, for each site describe any additional disposal methods that will be used and whether 

the waste is subject to secondary or tertiary on-site treatment. b. Estimate the amount released to the environment after control 

technology (in kg/day). 

(6)- Mark (X) this column if entries in columns (4) and (5) are confidential business information (CBI). 

(7)- Identify the destination(s) of releases to water. Please supply NPDES (National Pollutant Discharge Elimination System) numbers for 

direct dischargers or NPDES numbers of the POTW (Publicly Owned Treatment Works). Mark (X) if the POTW name or NPDES # 

(1) 

I 

is confidential business information 

Amount of new substance 

released 

(2a) (2b) 

-

(3) 

fZI 

(5b) 

-

Page 

CBI 

(6) 

fZI 

12 
. 0 ' ' 0 0 ' 

0 ' ' 0 0 ' 

0 ' ' 0 0 ' 

0 ' ' 0 0 ' 

(7) Mark (X) the [glporw provide name(s) below: CBI [gl Navigable 0 Other -Specify Provide NPDES # CBI 

destinations of - waterway releases to [gl - [gl water. 

D Mark (X) this box if you attach a continuation sheet. 

Page 13 
c 

Part II- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued 

~ Section B-INDUSTRIAL SITES CONTROLLED BY OTHERS 

Complete Section B for typical processing or use operations involving the new chemical substance at sites you do not control. Importers do 

not have to complete this section for operations outside the U.S.; however, you must report any processing or use activities after import. See 

the Instructions Manual. Complete a separate section B for each type of processing, or use operation involving the new chemical substance. 

If the same operation is performed at more than one site describe the typical operation common to these sites. Identify additional sites on a 

continuation sheet. 

1. Operation Description- To claim information in this section as confidential, circle or bracket the specific information that you claim 

as confidential. 

(1)- Diagram the major unit operation steps and chemical conversions, including interim storage and transport containers (specify e.g. 5 

gallon pails, 55 gallon drums, rail cars, tank trucks, etc). On the diagram, identify by letter and briefly describe each worker activity. (2) 

-Provide the identity, the approximate weight (by kg/day or kg/batch, on an 100% new chemical substance basis), and entry point of all 

feedstocks (including reactants, solvents, and catalysts, etc) and of all products, recycle streams, and wastes. Include cleaning chemicals 

(note frequency if not used daily or per batch). (3)- Identify by number the points of release, including small or intermittent releases, to 

the environment of the new chemical substance. (4) Please enter the# of sites (remember to identify the locations of these sites on a 

continuation sheet): 

#OF SITES 

D Mark (X) this box if you attach a continuation sheet. 

2. Worker Exposure/Environmental Release 

(1)- From the diagram above, provide the letter for each worker activity. Complete 2-8 for each worker activity described. 

(2)- Estimate the number of workers exposed for all sites combined. 

(4)- Estimate the typical duration of exposure per worker in (a) hours per day and (b) days per year. 

( 6) - Describe the physical form of exposure and % new chemical substance (if in mixture), and any protective equipment and 

engineering controls used to protect workers. 

(7) - Estimate the percent of the new substance as formulated when packaged or used as a final product. 

(9) - From the process diagram above, enter the number of each release point. Complete 9-13 for each release point identified. 

(10)- Estimate the amount of the new substance released (a) directly to the environment or (b) into control technology to the 

environment (in kg/day or kg/batch). 

(12)- Describe media of release i.e. stack air, fugitive air (optional-see Instructions Manual), surface water, on-site or off-site land or 

incineration, POTW, or other (specify) and control technology, if any, that will be used to limit the release of the new substance 

to the environment. 

(14)- Identify byproducts which may result from the operation. 

(3), (5), (8), (11), (13) and (15)- Mark (X) this column if any of the proceedin~ entries are confidential business information (CBI). 

Letter Protective Equip./ %in Media of Release & 

of #of Workers CBI Duration of CBI Engineering Controls/ Form- CBI Release Amount of New CBI Control CBI Act- Exposed Exposure Physical Form and% new ulation Number Substance Released Technology ivity substance 

(1) (2) (3) (4a) (4b) (5) (6) (7) (8) (9) (lOa) (lOb) (11) (12) (13) 

D D D D D 

D D D D D 

D D D D D 

D D D D D 

(14)- Byproducts: (15) 

D 

D Mark (X) this box if you attach a continuation sheet. 

Page 14 
OPTIONAL POLLUTION PREVENTION INFORMATION 

To claim information in this section as confidential circle or bracket the specific information that you claim as confidential. 

In this section you may provide information not reported elsewhere in this form regarding your efforts to reduce or 

minimize potential risks associated with activities surrounding manufacturing, processing, use and disposal of the 

PMN substance. Source reduction includes the reduction in the amount or toxicity of chemical wastes by 

technological modification, process and procedure modification, product reformulation, raw materials substitution, 

and/or inventory control. Recycling refers to the reclamation of useful chemical components from wastes that would 

otherwise be treated or released as air emissions or water discharges, or land disposal. Descriptions of pollution 

prevention, source reduction and recycling should emphasize potential risk reduction subsequent to compliance with 

existing regulatory requirements and can be either quantitative or qualitative. The EPA is interested in this 

information to assess overall net reductions in toxicity or environmental releases and exposures, not the shifting of 

risks to other environmental media or non-environmental areas (e.g., occupational or consumer exposure). In 

addition, information on the relative cost or performance characteristics of the PMN substance to potential 

alternatives may be provided. All information provided in this section will be taken into consideration during 

the review of this substance. See the revised Instructions Manual that includes a Pollution Prevention manual 

for guidance and examples. 

Describe the expected net benefits, such as (I) an overall reduction in risk to human health or the environment; (2) a reduction in the volume 

manufactured; (3) a reduction in the generation of waste materials through recycling, source reduction or other means; (4) a reduction in 

potential toxicity or human exposure and/or environmental release; (5) an increase in product performance, a decrease in the cost of 

production and/or improved operation efficiency of the new chemical substance in comparison to existing chemical substances used in 

similar application; or (6) the extent to which the new chemical substance may be a substitute for an existing substance that poses a greater 

overall risk to human health or the environment. 

D Mark (X) this box if you attach a continuation sheet. 

Page 15 
Part III-LIST OF ATTACHMENTS 

Attach continuation sheets for sections of the form and test data and other data (including physical/chemical properties and structure/activity 

information), and optional information after this page. Clearly identify the attachment and the section of the form to which it relates, if 

appropriate. Number consecutively the pages of the attachments. In the column below, enter the inclusive page numbers of each attachment. 

Mark (X) the "Confidential" box next to any attachment name you claim as confidential. Read the Instructions Manual for guidance on how 

to claim any information in an attachment as confidential. You must include with the sanitized copy of the notice form a sanitized version of 

any attachment in which you claim information as confidential. 

Attachment Name Attachment page Confnumber(s) dential 

Material Safety Data Sheet Attachment 1 ~ CAS Inventory Expert Services Report Attachment 2 ~ -Waste Water System Attachment 3 ~ 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D 

D Mark (X) this box if you attach a continuation sheet. Enter the attachment name and number. 

Page 16 
PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET 

To assist EPA's review of physical and chemical properties data, please complete the following worksheet for data you provide and 

include it in the notice. Identify the property measured, the page of the notice on which the property appears, the value of the property, 

the units in which the property is measured (as necessary), and whether or not the property is claimed as confidential. The physical 

state of the neat substance should be provided. These measured properties should be for the neat (100% pure) chemical substance. 

Properties that are measured for mixtures or formulations should be so noted (% PMN substance in _). You are not required to submit 

this worksheet; however, EPA strongly recommends that you do so, as it will simplify review and ensure that confidential information 

is properly protected. You should submit this worksheet as a supplement to your submission oftest data. This worksheet is not a 

substitute for submission of test data. 

Property Mark 

(X) if 

provided 

Page 

number 

Value Measured 

or 

Estimate 

(MorE) 

Confidential 

Mark 

(a) (b) (c) (X) 

state of neat substance 

t 

t 

Dissociation constant 

Particle size distribution 

'sLaw constant 

Volitalization from water 

Volitalization from soil 

concentration 

M 

Page 17 
ATTACHMENT 1 

Material Safety Data Sheet 
ATTACHMENT 2 

CAS Inventory Expert Services Report 
ATTACHMENT 3 

Waste Water System