EPA Form 8570-4 (Rev. 8-94) Reverse 

### *U.S. GOP: 2000-519-239/94558 

# Instructions and Paperwork Act Notice Please Read Carefully Before Completing This Form

Paperwork Reduction Act Notice

The public reporting burden for this collection of information is estimated to average 1.0 hour per response, including familiarizationwith the form, organizing the necessary information, and completing the form. Send any comments 

# regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Chief, Information Policy Branch, 2136, U.S. 

# Environmental Protection Agency, 401 M Street, S.W., Washington, D.C. 20460.

Instructions

The complete chemical composition ofeachpesticidemustbeknown so it can he evaluated for registration under the Federal Insecticide, Fungicide, and Rodenticide Act, as amended.

This form is designed for reporting the ingredients used in the formulation of

apesticideproduct. It mustbe completed and submitted with each application for new registration ofa pesticide and application for amended registration if the revision involves a formula change.



### Block A: Check the appropriate action for which you are submitting the form.



### Block B: Number all pages consecutively. Enter on each page the total number ofpages submitted. Ifmore than onepage is required, number them 

### "1 of 2", "2 of2", "3 of 3", etc.

1. Name and Address ofApplicant/Registrant: Enter the name and address of your firm or authorized agent.



### 2. Name and Address ofProducer: Specify the name ofthe producer and the address of the site where this product will be produced.



### 3. Product Name: Specify the complete name ofthispesticideproduct as it will appear on the label. This name must be the same as that which appears on the application form. 

### 4. Rcgistlation Number/Filc Symbol: Enter the EPA registration number or file symbol, if known for this product



### 5. EPA Product Manager/Team Number: Enter the name and team number of the EPA Product Manager assigned to this product, if known. 

### 6. Country Where Formulated: Specify the country where this product is 

### formulated

7. Weight per Gallon/Bulk Density: For a liquid product specify pounds per 

### gallon of formulated product. For a powder or granular product, enter the hulk density of formulated product (as used). Enter weight per unit if the product is produced as a tablet, briquette, or other uniformly shaped product 

### 8. pH: Enter the pH ofaqueous formulations and products which are either dispersible or soluble in water. If not applicable enter "N/A".



### 9. Flash Point/Flame Extension: Specify the flash point as determined by the regulations forpressurizedproducts and/orproducts known or suspected
to burn. State the results ofthe flame extension test for pressurized products including positive flashbacks.



### 10. Components in Formulation: List as actually introduced into the formulation. For each component in your formulation, provide the product name, commonly accepted chemical, the trade name, and the Chemical Abstract (CAS) number for each identifiable ingredientpresent in theproduct. CAS numbers may be obtained from the Chemical Abstract Service of the 

### American Chemical Society, Columbus, OH. For each original and alternate source ofeach active ingredient in the product, indicate the percent purity of the manufacturing use product, technical product, or other source ofactive ingredient. Ifone or more components will be obtained from more than one 

### source, enter all alternate sources and all alternate EPA Reg. Nos. in blocks 10, 11, and 12 or on a separate attachment.

Attention: (SpecialInstructions forColumns 10, 13, and 14) Any 

### impurities greater than or equal to 0.1% (or less than 0.1% if the impurity is toxicologically significant) which are associated with the active ingredient(s) 

### ofn technical grade (manufacturing or reformulating use) product or an end use product produced by an integrated formulations system should also be listed in column 10, and the corresponding amount, percent by weight, and 

### upper certified limits in columns I3 and 14.

11. Supplier Name and Address: Provide the name and address of the supplier ofeach component in the formulation. Ifone or more components will be obtained from more than one source, specify the names addresses of the alternate sources also. 

### 12. EPA Reg. No.: Specify the EPA registration number, ifany, for each active ingredient in the formulation. Ifan unregistered active ingredient is used, have the suppliers submit the chemical specifications, as well as any 

### data required under 40 CFR Part 158.

13. Each Component in Formulation a. Amount: Specify the quantity of each component as actually introduced into the formulation. Units (e.g., pounds, grams, gallons, liters) should be expressed as used in the formulation. If the quantity is a liquid measure, enter the volume and the specific gravity or the pounds per gallon of the component.



### b. Percent by Weight: Specify the weight percentage ofeach component in 

### your formulation. Check Your Calculations. Note that the weight percentage in many cases will not agreewith that shown on the label ingredient statement where the weight percentage ofthe per active ingredient(s) must he declared. 

### Attention: Producers of Microbial Products: Special Instructions for
Column 13b.) Please state the percent of active ingredient in British 

### International Units (BIUs). International Toxic Units (ITUs). Polyhedral Inclusion Bodies (PIBs)(viruses), Colony Forming Units (CFUs)(Fungi), as appropriate, and include an equivalent statement of active ingredient per 

### milligram, ounce, pound, etc. of product (e.g., a 50% active Bacillus thuringiensis product may have an equivalency value of 1.59 million Aedis aegypti ITU per pound of product.



### 14. Certified Limits: These limits are to be set based on representative sampling and chemicnl analysis (i.e., quality control) of the product.



### a. Upper Limit: Specify the maximumpercentage ofeach active ingredient, 

### intentionally added inert ingredient, and any impurities greater than 0.1% to he permitted in the product.



### b. Lower Limit: Specify the minimumpercentage ofeach active ingredient and intentionally added inert ingredient to he permitted in the product.



### 15. Purpose In Formulation: Specify the purpose ofeach ingredient both active and inert. (For example, disinfectant, herbicide, synergist surfactant, defoamer, sequestrant, etc.) If space is insufficient, abbreviate.



### 16. Typed Name ofApproving Offirial: Complete this item for identification of individual to he contacted if necessary



### 17. Total Weight: Specify the total weight of the batch (column 13a.) 

### 18-21: Complete these items for identification ofindividual tobe contacted if
necessary.