OMB Control No. 20XX

- XXXX

Approval expires XX/XX/XXXX



## Environmental

Protection Agency Confidential Statement of Product

Specifications

- DRAFT Health

Canada 1.

Page of

 Please read the instructions  Please type or print clearly in black ink  Leave shaded areas blank  This form can be saved using Adobe Acrobat

Preliminary

Questions 

### 2.

Canadian Registration

US Registration 3. PMRA Formulation # & Version # 4. EPA Basic Formulation

OR Alternate Formulation No. Date Received Submission/File No.

5. Is the product a Repack? 6 . Is the product a Microbial? 7 . Does the product have food uses?

8 . What is the product type? Technical Grade Active Ingredient Integrated Systems Product End Use Product Manufacturing Concentrate

General Information

Product 9

. Product Name 10

. Product Regn No. 1 1

. Name of Applicant/Registrant

Properties 1 2

. Formulation Type Code 1 3

. Specific Gravity/Density Units

to 1 4

. @ Temp Units 1 5

. Weight/Formulat ed Piece Units

1 6

. Flash Point Units 1 7

. Flame Extension Units 18

. Viscosity (mPa(s) ) 19

. pH Range

Certification of Approving Official Company Code

“I certify that all the information contained within this form is true and complete”

2 0 . Is this CSPS being provided on behalf of another Applicant/Registrant (3 rd 

### Party Confidential)? Yes No

2 1

. Position Title 2 2

. Name 2 3

. Signature

2 4 . Address 2 5 . City

2 6 . Province/State 2 7 . Country 2 8 . Postal Code/ZIP

29

. Date 3 0

. Phone No. 3 1

. Fax 3 2

. em ail

Agency/Office Review

S creened

by Date Reviewer

Approved by Date Reviewer YYYY

- MM

- DD XXX

- XXX

- XXXX XXX

- XXX

- XXXX

YYYY

- MM

- DD YYYY

- MM

- DD YYYY

- MM

- DDOMB Control No. 20XX

- XXXX

Approval expires XX/XX/XXXX

Product Name Product Registration No. Date Received Submission/File No. 1.

Page of



### Components

Names 33

. Row 34

. Active Formulant/Inert Impurity 36

. Trade Name 37

. Common Name (ISO Proposed or Accepted) 38

. Chemical Name (IUPAC or CAS name if applicable)

46

. %w/

w 35

. Is this a member of a set of multiple active

guarantees, or alternate formulants/inerts?

Yes Set

Informatio

n and

Limits 39 . Reg. or Sub/File No. 40 .%Purity 41 . CAS# 42 . Purpose in Formulation 43 . % LCL 44 . % Nominal 45 . % UCL

Label

Guarantee 47 . Label Guarantee 48 . Value 49 . Units Certified Limits of Label Guarantee

(for pure active ingredient) 5 0 . LCL 51 . UCL

Microbial

and Other 52 . Culture Collection Deposit 53 . Potency 54 . Viability 55 . Other information

Admin. ACT IN ACT OUT NACT LIST ACTIONS PC Codes

Names 33. Row 34. Active Formulant/Inert Impurity 36. Trade Name 37. Common Name (ISO Proposed or Accepted) 38. Chemical Name (IUPAC or CAS name if applicable)

46.

%w/

w 35. Is this a member of a set of multiple active

guarantees, or alternate formulants/inerts?

Yes Set

Informatio

n and

Limits 39. Reg. or Sub/File No. 40.%Purity 41. CAS# 42. Purpose in Formulation 43. % LCL 44. % Nominal 45. % UCL

Label

Guarantee 47. Label Guarantee 48. Value 49. Units Certified Limits of Label Guarantee

(for pure active ingredient) 50. LCL 51. UCL

Microbial

and Other 52. Culture Collection Deposit 53. Potency 54. Viability 55. Other information

Admin. ACT IN ACT OUT NACT LIST ACTIONS PC Codes

Names 33. Row 34. Active Formulant/Inert Impurity 36. Trade Name 37. Common Name (ISO Proposed or Accepted) 38. Chemical Name (IUPAC or CAS name if applicable)

46.

%w/

w 35. Is this a member of a set of multiple active

guarantees, or alternate formulants/inerts?

Yes Set

Informatio

n and

Limits 39. Reg. or Sub/File No. 40.%Purity 41. CAS# 42. Purpose in Formulation 43. % LCL 44. % Nominal 45. % UCL

Label

Guarantee 47. Label Guarantee 48. Value 49. Units Certified Limits of Label Guarantee

(for pure active ingredient) 50. LCL 51. UCL

Microbial

and Other 52. Culture Collection Deposit 53. Potency 54. Viability 55. Other information

Admin. ACT IN ACT OUT NACT LIST ACTIONS PC Codes

56 . Total weight (%) YYYY

- MM

- DDOMB Control No. 20XX

- XXXX

Approval expires XX/XX/XXXX

Product Name Product Registration No. Date Received Submission/File No. 1.

Page of



### Sites & Suppliers

57

. Manufacturing Site

Formulating Site

Formulant Supplier 58

. Row Number(s) of

the Component(s) 59 . Name 6 0 . Address 61 . City

Company

Code

62 . Province/State 63 . Country 64 . Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

57. Manufacturing Site

Formulating Site

Formulant Supplier 58.

Row Number(s) of

the Component(s) 59. Name 60. Address 61. City

Company

Code

62. Province/State 63. Country 64. Postal Code/ZIP

PMRA/ARLA 6003 ( xx / 20xx ) EPA Form 8570

- 4 (Rev. X

- XX ) YYYY

- MM

- DD