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United States Environmental Protection Agency

Washington, DC 20460

 Dioxins / Furans Report

Form approved

OMB No. 2070-0054

When completed send this form to: For Agency Use Only

 Document Control Officer

 Office of Pollution Prevention and Toxics, 7407M

 U.S. Environmental Protection Agency

 1201 Pennsylvania Avenue N.W.

 Washington, DC 20460

Document Control Number Docket Number

Part I - General Information

Section A - Submitter Identification ConfiMark (X) dential the "Confidential" box next to any subsection you claim as confidential

1a. Person

Submitting

Notice

Name of authorized official Title

Company

Mailing address (number and street)

City, State, and ZIP code

Section B - Chemical Identity Information (Use a separate form for each chemical reported)

Mark (X) the "Confidential" box next to any subsection you claim as confidential

1. Chemical name and CAS Registry Number

Part II - Process and Release Information

Section A - Flow Diagram

Mark (X) the "Confidential" box next to any subsection you claim as confidential

Complete this section for each unit process. Provide a general process block flow diagram that identifies major 

unit operations and treatment processes and indicate the types and points of release of byproducts and 

residuals. (See example 1 attached.)

(1) Include intermediates, co-products and byproducts produced by the process.

(2) Provide a block for each major unit operation (e.g., reactor, washer, filtration, air emission control, aeration 

lagoon, etc.) in the production process and in the residuals management process.

(3) Identify process input such as raw materials, reagents, and solvents by chemical or common name and CAS 

number, and indicate the point of introduction with arrows.

(4) For each unit operation in which the temperature is not ambient, specify temperature or temperature range in 

each block of the flow diagram.

(5) Specify operating pressure or pressure range in each block of the flow diagram for each unit operation in 

which the pressure is not atmospheric.

(6) Identify the composition of the reaction vessel wherever one is used (e.g., stainless steel, glass-lined)

(7) Number all points in the flow diagram from which the chemical substance will be released into the 

environment. (See example 1.)

□ Mark (x) this box if you attach a continuation sheet

EPA Form 7710-51
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Section B - Environmental Release and Disposal

You must make separate confidentiality claims for the release number and the amount of the substance released and 

other release and disposal information. Mark (x) in 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.

(2) Estimate the amount of the chemical substance released directly to the environment or into control technology (in 

kg/day or kg/batch).

(3) Mark (x) this column if entries in columns (1) and/or (2) are confidential.

(4) Identify the media (air, land or water) to which the substances will be released from the release point.

(5) Describe the control technology, if any, that will be used to limit the release of the substance to the environment. For

releases disposed of on land, characterize the disposal method.

(6) Mark (x) this column if entries in columns (4) and/or (5) are confidential.

(7) Identify the destination(s) of releases to water.

Release 

number

(1)

Amount of substance 

released

(2)

Confidential

(3)

Media of 

release

(4)

Control technology

(5)

Confidential

(6)

(7) Mark (x) the destination(s) □ POTW (Publicly owned □ Navigable □ Other

 of releases to water treatment works) water (Specify)

□ Mark (x) this 

box if you attach a 

continuation sheet

EPA Form 7710-51
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Part III - Production, Import, and Use Information

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

1. Production volume - Report the production volume during the past 12 months of production. Also report the 

maximum production volume for any consecutive 12-month period during the past 3 years of production.

Confidential

Past 12-month production (kg/year) Maximum 12-month production (kg/year)

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 substance, and other use information. Mark (x) the 

"Confidential" box next to any item you claim as confidential.

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

(2) Mark (x) this column if entry in column (3) is confidential.

(3) Estimate the percent of total production for the past 3 years is devoted to each category of use.

(4) Mark (x) this column if entry in column (3) is confidential.

(5) Estimate the percent of the 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.

(6) Mark (x) this column if entry in column (5) is confidential.

(7) Mark (x) whether the use is site-limited, industrial, commercial or consumer. Mark more than one column if appropriate.

(8) Mark (x) this column if entries in column (7) are confidential.

Read the Instructions for examples.

Category of use

(1)

Confidential

(2)

Production

(percent)

(3)

Confidential

(4)

Formulation

(percent)

(5)

Confidential

(6)

Mark (x) appropriate column(s)

(7)

Confidential

(8)

SitelimitedIndustrialCommercialConsumer

□ Mark (x) this box if you attach a continuation sheet

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

material safety data sheet, or other information that will be provided to any person regarding protective equipment or 

practices for the safe handling, transport, use, or disposal of the new chemical substances. List in Part IV any hazard 

information you include.

□ Mark (x) this box if you attach hazard information.

EPA Form 7710-51
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4. Occupational Exposures - You must make separate confidentiality claims for the description of worker activity, physical 

forms of the substances, number of workers exposed, and the duration of activity. Mark (x) in the "Confidential" box next 

to any item you claim as confidential.

(1) Describe the activities in which workers may be exposed 

to the chemical substance. Include activities in which 

workers wear protective equipment. 

(2) Mark (x) in this column if entry in column (1) is 

confidential. 

(3) Indicate the physical form(s) of the chemical substance 

at the time of exposure. 

(4) Mark (x) in this column if entry in column (3) is 

confidential. 

(5) Estimate the maximum number of worked involved in 

each activity. 

(6) Mark (x) in this column if entry in column (5) is 

confidential. 

(7) and (8) Estimate the maximum duration of the activity for 

any worker in hours per day and days per year. 

(9) Mark (x) in this column if entries in columns (7) 

and/or (8) are confidential. 

Worker Activity 

(1)

Confidential 

(2)

Physical 

Forms 

(3)

Confidential 

(4)

Maximum 

Number 

(5)

Confidential 

(6)

Maximum Duration Confidential 

(9) Hrs/Day 

(7)

Days/Yr 

(8)

□ Mark (x) this box if you attach a continuation sheet

EPA Form 7710-51
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Part IV - List of Attachments

Attach continuation sheets for sections of the form 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 column (2) below, enter the inclusive page numbers of each attachment. 

Mark (x) in the "Confidential" box next to any attachment name you claim as confidential. Read the Instructions for 

guidance on how to claim any information in an attachment confidential.

Attachment name 

(1)

Attachment 

page numbers 

(2)

Confidential 

(3)

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

Certification

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

1. The company named in Part I, Section 1a. of this form manufactures, imports, or processes, other than in small 

quantities for research purposes, 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.

Signature of authorized official Date Confidential

Signature of agent (if applicable) Date Confidential

EPA Form 7710-51
Instructions

EPA Form 7710-41, Dioxins / Furans Report

You must provide all information requested in this form to 

the extent that it is known to or reasonably ascertainable 

to you.

Part 1 - General Information

You must provide the chemical identity of the chemical 

substances reported on, even if you claim the identity as 

confidential.

Part II - Process and Release Information

You may need additional copies of Part II, Sections A and 

B if there are several manufacturing operations that you 

will describe in the form. You should reproduce these 

sections as needed.

Part III - Production, Import, and Use Information

You must provide production volume, percent of production used for each use category, and whether use is 

industrial, commercial, or consumer. Also included is a 

copy of any hazard warning and a report of occupational 

exposure. Copies may be made of any part of the form if 

additional space is needed.

Part IV - List of Attachments

You should attach additional sheets if you do not have 

enough space on the form to answer a question fully. In 

Part IV, list all attachments you include with the form.

Optional Information

You may include with the form any information that you 

want EPA to consider in evaluating the substance.

Confidentiality Claims

You may claim any information in this form 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.

A. General Instructions

Complete the form using a typewriter or by printing legibly in black ink. All information must be in English. 

Provide all information requested on the form to the extent 

that you know or can reasonably ascertain it. You may 

attach continuation sheets to any subsection or item on 

the form. Mark (x) the appropriate box on the form if you 

attach continuation sheets.

The use of the term "manufacture" in this form includes 

both manufacture and import. Manufacturers and 

importers must fully comply with the information requirements set forth in the Polyhalogenated Dibenzo-p-dioxins / 

Dibenzofurans Testing and Reporting Requirements Rule. 

However, importers are not required to submit any data 

under section 8(a) of the Toxic Substances Control Act 

(TSCA) that relates solely to exposure of humans or the 

environment outside of the United States.

Any manufacturer or importer using this form may photocopy the form, sections of the form, or these instructions

as frequently as needed.

EPA Form 7710-51

B. Certification

The official named in Part I, Section A of the form, as the 

person submitting the notice, must sign the certification on 

page 6 of the form. This official is responsible for the truth 

and accuracy of each statement in the certification.

C. Asserting Confidentiality Claims

A manufacturer or importer may assert a claim of confidentiality for any information submitted to EPA on this form. To 

assert confidentiality claims for specific information on the 

form (e.g., submitter identity, process data, or use information), mark (x) in the "Confidential" box on the form located 

to the right of the information. Marking these boxes will 

provide a quick reference for EPA to determine what 

information is confidential, thus aiding proper treatment of 

confidential business information.

Part I - General Information

Section A - Submitter Identification

Person submitting notice - Enter information on the official 

who signs the general Certification on page 6.

Section B - Chemical Identity Information

Chemical name and CAS registry number - List the common 

name and Chemical Abstracts Service registry number, if 

available, for the chemical on which you are reporting.

Part II - Process and Release Information

Section A - Flow Diagram

Flow diagram - Submit a block flow diagram for each major 

unit operation and treatment process involved in the manufacture of the chemical on which you are reporting. Include 

the following information:

(1) Identify the product process and chemical intermediates, 

co-products, and byproducts produced by the process;

(2) Provide a block for each major unit operation (e.g., 

reactor, washer, filtration, air emission control, aeration 

lagoon, etc.) in the production process and in the residuals 

management process;

(3) Identify all process inputs such as raw materials, 

reagents, solvents, etc. by the chemical or common name 

and CAS number, and indicate the point of introduction with 

arrows.

(4) For each unit operation in which the temperature is not 

ambient, specify temperature or temperature range in each 

block of the flow diagram.

(5) For each unit operation in which the operating pressure 

is not atmospheric, specify pressure or pressure range in 

each block of the flow diagram.

(6) Identify the composition of the reaction vessel wherever 

one is used.

(7) Number all points in the flow diagram from which the 

chemical substance will be released into the environment. 

See the example provided.
Section B - Environmental Release and Disposal

Column (1) - For each release point indicated in the flow 

diagram (Part I, Section A), enter the corresponding 

number.

Column (2) - Estimate the amount of the chemical (in 

kg/day for continuous operations or kg/batch for batch 

operations) that will be released from the release point 

before entering control technology. Base your estimate on 

your maximum 12-month production volume.

Column (4) - Enter the medium (air, water, land) into which 

the release stream discharges (whether or not control 

technology is used).

Column (5) - For releases to the air and water, describe the 

type of technology used to control the release of the 

chemical. Examples of control technologies include carbon filter, scrubber, and biological treatment (primary, 

secondary, etc.). Give as complete a description as possible. Enter "none" if no control technology is used and the 

substance is released directly to the environment. For 

disposal on land, describe the landfill site construction 

(including liners) and handling procedures. Describe 

landfill containers.

Column (7) - Mark (x) the appropriate box and/or specify 

other destinations of water releases.

Columns (3) and (6) - Note that you must make separate 

confidentiality claims for the release number and amount 

of chemical substance released and other release and 

disposal information.

Part III - Production, Import, and Use Information

Production Information

Production volume - Report the production volume for the 

past 12 months of production. Also report the maximum 

production volume during the past 3 years of manufacture. 

Provide this information in kilograms. Include in your 

report the amounts produced by persons under contract 

to you. If part of the amount manufactured is for export, 

include this amount in your reports.

Use Information

Column (1) - Identify each possible category of use of the 

chemical substance by describing its function and application. "Function" is related to the inherent physical and 

chemical properties of the substance, (e.g., degreaser, 

catalyst, plasticizer, ultraviolet absorber). "Application" 

refers to the use of the substance in particular processes 

or products (e.g., a degreaser may be used for cleaning of 

fabricated metal parts). Following are some examples of 

how you should describe categories of use:

- a disperse dye carrier for finishing polyester fibers

- a cross-linking agent for epoxy-like coatings for metal 

surfaces

- a flame retardant for surface application on cotton 

apparel, textile home furnishing, and exterior canvas 

products

- a surfactant in automobile spray wax

- a colorant for paper and other cellulosics

Column (3) - Report the percent of the total production 

volume during the past 12 months manufactured for each 

category of use.

EPA Form 7710-51

Column (5) - Estimate the weight percent of the chemical 

substance contained in any formulated mixture, suspension, 

emulsion, solution, or gel associated with each category of 

use as manufactured for commercial purposes at sites under 

your control. Where the substance is not distributed from 

your site neat, enter N/A for Not Applicable.

For example:

 Formulated 

Product as Percent of ChemiCategory of Use Manufactured cal Substance

Cross-linking agent none; distributed N/A

for epoxy-type neat

coatings for metal

surfaces

Flame retardant for none; distributed N/A

cotton apparel neat

Surfactant in spray auto wax 4

automobile spray (suspension)

wax

Colorant for paper colorant (solution) 56

and other

cellulosics

Column (7) - Mark (x) to indicate if the category of use is sitelimited. Also mark (x) to indicate whether the use is for 

industrial, commercial, and/or consumer use as defined 

below. Mark more than one box if appropriate. For example, 

a surfactant in an automobile wax may have a consumer use 

in liquid wax, a commercial use in auto washes, and an 

industrial use by automobile manufacturers.

Site-limited: The substance is used only on the contiguous 

property unit where it is manufactured and not intentionally 

distributed outside that site except for waste disposal. This 

includes all factories, storage spaces, and warehouses at the 

site. An example would be an intermediate that is further 

reacted on-site to produce a chemical product.

Industrial: The chemical substances or products containing 

the substance are used only at the site of other manufacturers or processors, e.g., textile dyeing, paint formulation, 

use of a resin to manufacture an article.

Commercial: The chemical substances or products 

containing the substance are used only by a commercial 

enterprise providing a consumer service, e.g., use by commercial dry cleaning establishments, use by painting 

contractors, or use by roofers in commercial building 

construction.

Consumer: The chemical substances or products containing 

the substance are used by private individuals in or around a 

residence, or during recreation, or for any other personal use 

or enjoyment, e.g., automotive polish, dyed wearing apparel, 

household cleaners, etc.

Columns (2), (4), (6), (8) - Note that you must make separate 

confidentiality claims for the description of the category of 

use, the percent of production devoted to each category, and 

other use information. The information in this section is used 

to evaluate potential exposure to the chemical. If you wish to 

provide any additional information that would assist in this 

analysis, it may be submitted as optional information.
C. Hazard Information

Include with the form a copy or reasonable facsimile of 

any hazard warning statement, label, material safety data 

sheet, or other information that is provided to any person 

regarding protective equipment or practices for the safe 

transport, use or disposal of the chemical. Identify any 

copies of hazard information or warnings that you attach 

in Part IV, List of Attachments.

D. Occupational Exposure Information

Column (1) - Describe each specific activity in the 

operation during which workers may be exposed to the 

chemical. Such activities may include charging reactor 

vessels, sampling for quality control, transferring 

materials from one work area to another, drumming, bulk 

loading, changing filters, and cleaning equipment. 

Activities must be described even if workers wear 

protective equipment or clothing. (Recommended protecttive equipment should be included as part of Hazard 

Information.)

Column (3) - Indicate the physical form of the substance at 

the time of exposure, e.g., solid (crystals, granules, 

powder, dust), liquid (solution, paste, slurry, emulsion, 

mist, spray), gas (vapor, fumes), even if workers wear 

protective equipment.

Column (5) - Report the maximum number of workers 

involved in each specific activity, based on the reported 

maximum 12-month production volume.

Column (7) - Enter the maximum duration that any one 

worker will engage in the activity in hours/day, e.g., 8 

hours/day.

Column (8) - Enter the maximum duration that any one 

worker will engage in the activity in days/year, based on 

the reported maximum 12-month production volume, e.g., 

200 days/year.

Columns (2), (4), (6), (9) - Note that you must make 

separate confidentiality claims for the description of 

worker activity, physical form of the chemical, number of 

workers exposed, and duration of exposure.

Part IV - List of Attachments

Attach any continuation sheets for sections of the form, 

and any optional information, after the last page of the 

form. Clearly identify the attachment and the section to 

which it relates. Number consecutively the pages of the 

attachments. Enter the total number of pages in the form 

on the last line of the List of Attachments. Mark (x) the 

"Confidential" box next to any attachment you claim as 

confidential. See the section of these Instructions titled 

Confidentiality for guidance on claiming any information 

confidential.

Paperwork Reduction Action Notice: The public reporting 

and record keeping burden for this collection is estimated 

to average 31.5 hours per response, including the 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 this burden estimate or any 

other aspect of this collection of information, including 

suggestions for reducing the burden, to Director, 

Collection Strategies Division (Mail Code 2822T), U.S. 

Environmental Protection Agency, Washington, DC 20460. 

Include the OMB control number in any correspondence, 

but do not submit the form or report to this address. The 

EPA Form 7710-51

actual information or form should be submitted in 

accordance with the instructions accompanying the 

information or form, specified in the corresponding 

regulation.