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. 11. Name of Applicant/Registrant

Properties

12. Formulation Type Code 13. Specific Gravity/Density Units

 to 

14. @ Temp Units

 

15. Weight/Formulated Piece Units

 

16. Flash Point Units

 

17. 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”

20. Is this CSPS being provided on behalf of another Applicant/Registrant (3rd Party Confidential)? Yes No 

21. Position Title 22. Name 23. Signature

24. Address 25. City

26. Province/State 27. Country 28. Postal Code/ZIP

29. Date 30. Phone No. 31. Fax 32. email

Agency/Office Review

Screened 

by

Date

Reviewer

Approved by

Date

Reviewer

YYYY-MM-DD XXX-XXX-XXXX XXX-XXX-XXXX

YYYY-MM-DD YYYY-MM-DD

YYYY-MM-DD
OMB 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)

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

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-DD
OMB 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 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

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