Header Sheet for Creating Extra PMN Submission Pages: 

If your PMN needs extra pages, or is a consolidated PMN, fill out this page to instruct the 

electronic form on how many additional pages will be needed prior to entering your 

submission data. If this is not a consolidated form AND you do not require extra pages, you 

may skip this header page and proceed to the PMN form on the following page. 

For consolidated Section 5 submissions: 

(If not a consolidated submission skip to step 5 below.) 

1. Enter the prenotice communication number here . 

2. Does this consolidated PMN form cover polymer or nonpolymer substances? 

 Polymer Nonpolymer 

3. How many substances were approved for consolidation? 

2 3 4 5 6 

Based on your answers above, this software will generate required additional copies of pages 4 (if nonpolymer) or 5 (if 

polymer) and 6 and 7. 

4. Do you need additional copies of other pages for the member substances in this consolidation? If so, please check 

the corresponding box for the required extra pages below: (The corresponding pages you check will be generated for 

EACH substance, although you may not need the extra page for each substance. If you need more than one extra page 

8 and/or page 9 for member substances of your consolidation, you may request them under step 5 below.) 

 8 9 10 11 13 

For any Section 5 submission, consolidated or not:

5. For additional copies of pages 8 and 9 (to show different exposures resulting from manufacturing and processing), 

indicate the number of additional pages required here: 

 8 9 

6. If you have entered information for a consolidated PMN (steps 1 - 4) and/or requested additional pages under step 5, 

click on the following button to generate (spawn) the additional pages. 

The software will now spawn the required number of pages. This will take several minutes, and will not require additional 

input from you while it generates the pages.

Note: The PMN pages will be automatically numbered. This header page will not be included in the page count showing 

on the form itself.
EPA FORM 7710-25 (Rev. 5-95) Replaces previous editions of EPA Form 7710-25.

Form Approved. O.M.B. No. 2070-0012. Approval Expires 10-31-96.

U.S. ENVIRONMENTAL PROTECTION AGENCY AGENCY USE ONLY

Date of receipt

PREMANUFACTURE

NOTICE

FOR NEW CHEMICAL SUBSTANCES

When

completed

send this

form to

DOCUMENT CONTROL OFFICER

OFFICE OF POLLUTION PREVENTION

AND TOXIC SUBSTANCES, 7407

U.S. E.P.A. 1200 Pennsylvania, NW

WASHINGTON, D.C. 20460

Enter the total number of pages

 in the Premanufacture Notice

Document control number EPA case number

GENERAL INSTRUCTIONS TS - • You must provide all information requested in this form to the extent that it is known to or reasonably ascertainable by you. Make reasonable estimates if you do

not have actual data.

• Before you complete this form, you should read the “Instructions Manual for Premanufacture Notification” (the Instructions Manual is available from the Toxic

Substances Control Act (TSCA) Information Service by calling 202-554-1404, or faxing 202-554-5603).

• If a user fee has been remitted for this notice (40 CFR 700.45), indicate in the boxes above the TS-user fee identification number you have generated. Remember,

your user fee ID number must also appear on your corresponding fee remittance, which is sent to EPA, Washington Financial Management Center (3303), P.O.

360399M, Pittsburgh, PA 15251-6399, Attn. TSCA User fee.

Part I  GENERAL INFORMATION

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

chemical substance, even if you 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 fee 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.

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).

Part III  LIST OF ATTACHMENTS

Attach additional sheets if there 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, LVE, 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.

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

Test Data (Check Below any included in this notice)

• Environmental fate data Yes • Other data Yes

• Health effects data Yes Risk assessments

• Environmental effects data Yes 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)

PMN (Premanufacture Notice)

INTERMEDIATE PMN (submitted in sequence with final product PMN)

SNUN (Significant New Use Notice)

TMEA (Test Marketing Exemption Application)

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

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

LVE Modification LOREX Modification

IS THIS A CONSOLIDATED PMN? Yes

# of chemicals or polymers 

(Prenotice Communication # required, enter # on page 3)
EPA FORM 7710-25 (Rev. 5-95) Page 2

Public reporting burden for this collection of information is estimated to average 110 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, 1200 Pennsylvania Ave., N.W., 

Washington, D.C. 20460; and to the Office of Management and Budget, Paperwork Reduction Act (2070-0012), Washington, D.C. 20503.

CERTIFICATION -- A Printed copy of this signature page, with original signature, must be submitted

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

1. The company named in Part I, section A, subsection 1a 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:

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

statement that applies:

The Company named in Part I, Section 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

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)(1) or a Low release

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

statements:

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.

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

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

If this application is for an LVE 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. Confidential

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

Signature of agent - (if applicable) Date
EPA FORM 7710-25 (Rev. 5-95) Page 3

Part I -- GENERAL INFORMATION

Section A -- SUBMITTER IDENTIFICATION ConfiMark () the “Confidential” box next to any subsection you claim as confidential dential

1a. Person

Submitting

Notice (in U.S.)

Name of authorized official Position

Company

Mailing address (number and street)

City, State Postal Code

 b. Agent (if

applicable)

Name of authorized official Position

Company

Mailing address (number and street)

City, State Postal Code

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

Joint Submitter (if

applicable)

Name of authorized official Position

Company

Mailing address (number and street) City, State

Province, Country Postal Code

2. Technical

Contact (in

U.S.)

Name of authorized official Position

Company

Mailing address (number and street)

City, State Postal Code Telephone Area Code Number

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

EPA assigned a PC Number to the notice, enter the number. Mark (X)

if none

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).

Mark (X)

if none

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. Mark (X)

if none

6. Type of Notice - Mark (X)

1. Manufacture

Only

Binding Option

Mark (X)

2. Import

Only

Binding Option

Mark (X)

3. Both
EPA FORM 7710-25 (Rev. 5-95) Page 4

Part I -- GENERAL INFORMATION -- Continued

Section B -- CHEMICAL IDENTITY INFORMATION: You must provide a currently correct Chemical Abstracts (CA) name of the substance based on the ninth

Collective Index (9CI) of CA nomenclature rules and conventions.

Mark (X) the “Confidential” box next to any item you claim as confidential

Complete either item 1 (Class 1 or 2 substances) or 2 (Polymers) as appropriate. Complete all other items.

If another person will submit chemical identity information for you (for either Item 1 or 2), mark (X) the box at the right.

Identify the name, company, and address of that person in a continuation sheet.

Confidential

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 Class 1 or 2 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,

which ever is appropriate based on CA 9CI nomenclature rules and conventions).

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

Method 1 (CAS Inventory Expert Service - a copy of the Identification

report obtained from the CAS Inventory Expert Services must be

submitted as an attachment to this notice)

Method 2 (Other Source)

d. Molecular formula CAS Registry Number

(if a number already

exists for the substance)

e. For a class 1 substance, provide a complete and correct chemical structure diagram. For a class 2 substance, provide a correct representative or

partial chemical structure diagram, as complete as can be known, if one can be reasonably ascertained. Please see the E-PMN Instruction Manual for

discussion of "native format" diagram software which can be helpful in reviewing your substance.

Mark (X) this box if you attach a continuation sheet.
EPA FORM 7710-25 (Rev. 5-95) Page 4a

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).

e. (1) List the immediate precursor substances with their respective CAS Registry Numbers.

e. (2) Describe the nature of the reaction or process.

e. (3) Indicate the range of composition and the typical composition (where appropriate).

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

Confidential Name (CAS #)
EPA FORM 7710-25 (Rev. 5-95) Page 5

Part I -- GENERAL INFORMATION -- Continued

Section B -- CHEMICAL IDENTITY INFORMATION -- Continued

2. Polymers (For a definition of polymer, see the Instructions Manual.) Confidential

a. Indicate the number-average weight of the lowest molecular weight composition of the polymer you intend to manufacture.

Indicate maximum weight percent of low molecular weight species (not including residual monomers, reactants, or solvents) below 500 and

below 1,000 absolute molecular weight of that composition.

Describe the methods of measurement or the basis for your estimates: GPC Other : (Specify below)

(i) lowest number average molecular weight: 

(ii) maximum weight % below 500 molecular weight: 

(iii) maximum weight % below 1000 molecular weight: 

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

b. You must make separate confidentiality claims for monomer or other reactant identity, composition information, and residual information. Mark (X) the

“Confidential” box next to any item you claim as confidential

(1) - Provide the specific chemical name and CAS Registry Number (if a number exists) of each monomer or other reactant used in the manufacture of

the polymer.

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

(3) - Indicate the typical weight percent of each monomer or other reactant in the polymer.

(4) - Choose “yes” from drop down menu if you want a monomer or other reactant used at two weight percent or less to be listed as part of the polymer

description on the TSCA Chemical Substance Inventory.

(5) - Mark (X) this column if entries in columns (3) and (4) are confidential.

(6) - Indicate the maximum weight percent of each monomer or other reactant that may be present as a residual in the polymer as manufactured for

commercial purposes.

(7) - Mark (X) this column if entry in column (6) is confidential.

Monomer or other reactant and CAS Registry Number

(1)

Confidential

(2)

Typical

composition

(3)

Include in

identity

(4)

Confidential

(5)

Maximum

residual

(6)

Confidential

(7)

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

Mark (X) this box if you attach a continuation sheet.
c. Please identify which method you used to develop or obtain the specified chemical identity information reported in this notice (check one). 

Method 1 (CAS Inventory Expert Service - a copy of the identification report Method 2 (other source)

CBI 

obtained from CAS Inventory Expert Service must be submitted as an attachment to this notice) 

d. The currently correct Chemical Abstracts (CA) name for the polymer that is consistent with TSCA Inventory listings for similar polymers.

 CAS Registry Number (if a number already exists for the substance) 

e. Provide a correct representative or partial chemical structure diagram, as complete as can be known, if one can be reasonably ascertained. . Please 

see the E-PMN Instruction Manual for discussion of "native format" diagram software which can be helpful in reviewing your substance. 

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

EPA FORM 7710-25 (Rev. 5-95) Page 5a 
EPA FORM 7710-25 (Rev. 5-95) Page 6

Part I -- GENERAL INFORMATION -- Continued

Section B -- CHEMICAL IDENTITY INFORMATION -- Continued

3. Impurities

(a) - Identify each impurity that may be reasonably anticipated to be present in the chemical substance as manufactured for commercial purpose. Provide

the CAS Registry Number if available. If there are unidentified impurities, enter “unidentified.”

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

Impurity and CAS Registry Number

(a)

Maximum

percent

(b)

Confidential

%

%

%

%

%

%

%

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

4. Synonyms - Enter any chemical synonyms for the new chemical identified in subsection 1 or 2. Confidential

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

5. Trade identification - List trade names for the new chemical substance identified in subsection 1 or 2.

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

6. Generic chemical name - If you claim chemical identify as confidential, you must provide a generic 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.

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 Registry

Number if available.

Byproduct

(1)

CAS Registry Number

(2)

Confidential

Mark (X) this box if you attach a continuation sheet.
Part I -- GENERAL INFORMATION -- Continued

Section C -- PRODUCTION, IMPORT, AND USE INFORMATION:

Mark (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 kg/yr, specify the volume and mark (x) in the binding box. If granted, you are bound to this volume 

Maximum first 12-month production (kg/yr) 

(100% new chemical substance basis)

Maximum 12-month production (kg/yr) 

(100% new chemical substance basis) 

Confidential 

Binding 

Option 

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 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 (1) (by function and application i.e. a 

dispersive dye for finishing polyester fibers)

CBI Binding

Option 

Mark 

(x) 

Production 

% 

CBI % in

Formu

lation 

CBI % of substance expected per use 

(8) 

CBI 

(2) (3) (4) (5) (6) (7) Sitelimited 

Consumer Industrial Commercial Binding

Option (9) 

% % 

% %

% %

% %

% %

% %

% %

* 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. 

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

b. Generic use 

description 

If you claim any category of use description in subsection 2a as confidential, enter a generic description of that category. Read the Instruction 

Manual for examples of generic use descriptions.

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 data sheet, or other

information which will be provided to any person who is reasonably likely to be exposed to this substance regarding protective equipment or practices for

the safe handing, transport, use, or disposal of the new substance. List in part III hazard information you include. 

Binding

Option 

Mark (x)

Mark (X) this box if you attach hazard information.

 EPA FORM 7710-25 (Rev. 5-95) Page 7
EPA FORM 7710-25 (Rev. 5-95) Page 8

Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE

Section A -- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER Mark (X) the “Confidential” box next 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 processing or use operations after import. You must describe these operations. See instructions manual

1. Operation description

a. Identity -- Enter the identity of the site at which the operation will occur.

Confidential

Name

 

 Site address (number and street)

 

City, County, State, ZIP code

 

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.

 

  

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

b. Type --

Mark (X) Manufacturing Processing Use

 

c. Amount and Duration -- Complete 1 or 2 as appropriate

1. Batch

Maximum kg/batch (100% new chemical

substance)

 

Hours/batch

 

Batches/year

 

 

2. Continuous

Maximum kg/day (100% new chemical

substance)

 

Hours/day

 

Days/year

 

 

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 (specify- 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 a 100% new chemical substance basis), and entry point of all starting materials and

feedstocks (including reactants, solvents, 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. If releasing to two media

at the same step, assign a second release number for the second medium.

Mark (X) this box if you attach a continuation sheet.
EPA FORM 7710-25 (Rev. 5-95) Page 8a
EPA FORM 7710-25 (Rev. 5-95) Page 9

Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued

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

2. Occupational Exposure -- You must make separate confidentiality claims for the description of worker activity, physical form of the new chemical substance, number of

works exposed, and duration of activity. Mark (X) the “Confidential” box next to any item you claim as confidential.

(1) -- Describe the activities (i.e. 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.

(12) -- Mark (X) this column if entries in columns (10) and (11) are confidential business information (CBI).

Worker activity CBI Protective Equipment/ Binding Physical

forms(s)

Binding CBI # of CBI Maximum duration CBI

(i.e., bag dumping, filling drums)

(1) (2)

Engineering Controls

(3)

Option

Mark (x)

(4)

and % new

substance

(5)

Option

Mark (x)

(6) (7)

Workers

Exposed

(8) (9)

Hrs/day

(10)

Days/yr

(11) (12)

Mark (X) this box if you attach a continuation sheet.
EPA FORM 7710-25 (Rev. 5-95)) Page 9a

3. Environmental Release and Disposal -- 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 1d(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 (stack air, fugitive air (optional-see Instruction Manual), surface water, on-site or off-site land or incineration, POTW, or other (specify)) to

which the new substance will be released from that release point.

(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 discharges or

NPDES numbers of the POTW (Publicly Owned Treatment Works). Mark (X) if the POTW name or NPDES # is confidential business information (CBI).

Release

Number

Amount of new

substance released

CBI Medium of

release

Control technology and efficiency (you may wish to optionally attach

efficiency data)

CBI

(1) (2a) (2b)

(3)

e.g. stack air

(4) (5a)

Binding

Mark

(X) (5b) (6)

(7) Mark (X) the destination(s) of releases to water. NPDES # CBI

POTW--provide

name(s)

Navigable waterway--

provide name(s)

Other--Specify

Mark (X) this box if you attach a continuation sheet.
EPA FORM 7710-25 (Rev. 5-95) Page 10

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(a). 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) -- Either in the diagram or in the text field 1(b) below, 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 all products, recycle streams, and wastes. Include cleaning chemicals (note frequency if not used daily or per batch). (3) -- Either in the diagram or in the

text field 1(b) below, 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

1(b). (Optional) This space is for a text description to clarify the diagram above.

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 physical form of exposure and % new chemical substance (if in mixture), and any protective equipment and engineering controls, if any, 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 proceeding entries are confidential business information (CBI).

Letter 

of 

Activity

# of 

Workers

Exposed 

CBI Duration Of

Exposure 

CBI Protective Equip. /Engineering Controls/Physical Form and/ % new substance % in

Formulation 

CBI 

(1) (2) (3) (4a) (4b) (5) (6) (7) (8)

Release 

Number 

Amount of 

New 

Substance 

Released 

CBI Media of Release & Control Technology CBI 

(9) (10a) (10b) (11) (12) (13)

(14) -- Byproducts: (15)

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

OPTIONAL POLLUTION PREVENTION INFORMATION

To claim information in the following 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. Please include new information 

pertinent to pollution prevention, including source reduction, recycling activities and safer processes or products available due to the new 

chemical 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 the information to

assess overall net reductions in toxicity or environmental releases and exposures, not the shifting of risks to other environmental media or nonenvironmental 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 PMN Instructions 

Manual and Pollution Prevention Guidance manual for guidance and examples.

EPA FORM 7710-25 (Rev. 5-95) Page 10a
EPA FORM 7710-25 (Rev. 5-95) Page 11

Optional Pollution Prevention Information (Continued) Describe the expected net benefits, such as (1) 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.

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

CBI
EPA FORM 7710-25 (Rev. 5-95) Page 12

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 any paper attachments. In the column below, enter the inclusive page

numbers of each attachment. Electronic attachments can be identified by filename.

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 Filename Attachment

page number(s)

Confidential

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

PAGE 13

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. If the attachments

are electronic, give the attachment number (found on page 12) at (b). 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 of test data. This worksheet is not a substitute for submission of test data.

Property

(a)

Mark (X)

if

provided

Page

number

(b)

Value

(c)

Measured or

Estimate

(M or E)

Confidential

Mark (X)

(d)

Physical state of neat substance (s) (l) (g)

Vapor pressure

@ Temperature °C Torr

Density/relative density g/cm3

Solubility

@ Temperature °C

Solvent g/L

Solubility in water @ Temperature °C g/L

Melting temperature °C

Boiling / sublimation temperature@ torr pressure °C

Spectra

Dissociation constant

Particle size distribution

Octanol / water partition coefficient

Henry’s Law constant

Volatilization from water

Volatilization from soil

pH @ concentration

Flammability

Explodability

Adsorption / coefficient

Other - Specify