Page 1 of 6

U nited S tates E nvironmental P rotection A gency

Washington, DC 20460



## Dioxin s / Furans Report Form approved

OMB No. 2070

- 0054

When completed send this form to : For Agency Use Only



### D ocument Control Off icer

O ffice of P ollution P revention and T oxics, 7407 M

U

. S

. Environmental Protection Agency

1201 P ennsylvania Avenue N.W. Washington, DC 2 0 460

Doc ument C ontrol Number Docket Number



### Part I

- General Information

Sec tion A

- Submitter Identification Conf i

dential Mark (X) 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, Sta te, 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

un it 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 un it 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 p ressure 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 f low 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

- 51Page 3 of 6



### 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 subst ances 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

n umber (1) Amount of substance

released (2) Confi

dential (3) Media of

release (4) Control technology (5) Confi

dential (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

- 51Page 4 of 6



### Part III

- Production, Import, and Use Information

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

1. P roduction 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. Co nfi

dential

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 ca tegory, 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 col umn 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) wheth er 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) Confi

dential (2) Produ ction

(percent) (3) Confi

dential (4) Formulation

(percent) (5) Confi

dential (6) Mark (x) appropriate column(s) (7) Confi

dential (8)

Site

limited Indus

trial Com

mercial Con

sumer



# □ 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 pers on 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.



# □ Ma rk (x) this box if you attach hazard information.

EPA Form 7710

- 51Page 5 of 6

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 ne xt 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 colum n 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 ent ry 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 th is column if entries in columns (7) and/or (8) are confidential.

Worker Activity (1) Confi

dential (2) Physical

Forms (3) Confi

dential (4) Maximum

Number (5) Confi

dential (6) Maximum Durat ion Confi

dential (9) Hrs/Day (7) Days/Yr

(8)



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

EPA Form 7710

- 51Page 6 of 6



### 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 whic h 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 th e Instructions for guidance on how to claim any information in an attachment confidential.

Attachment name (1) Attachment

page numbers (2) Confi

dential (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 Confi

dential

Signature of agent (if applicable) Date Confi

dential

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 i dentity 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

w ill 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 produc

tion 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 ha ve 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.

Confidentia lity Claims

You may claim any information in this form as confiden

tial. 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 infor mation you claim as confidential.

A. General Instructions

Complete the form using a typewriter or by printing legi

bly in black ink. All information must be in English. Provide all information requested on the form to the extent that you know or can reas onably 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 require

ments set forth in the Polyhalogenated Dibenzo

- p

- dioxins / Dibenzofurans Testing and Reporting Requirements Rule. However, importers are not required to submit any data

under secti on 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 photo

copy 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 accura cy of each statement in the certification.

C. Asserting Confidentiality Claims

A manufacturer or importer may assert a claim of confiden

tiality 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 informa

tion), 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 c onfidential, 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 manu

facture 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 th e 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 te mperature 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 D isposal

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 wi ll 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

tech nology 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 car

bon filter, scrubber, and biological treatment (primary, secondary, etc.). Give as complete a description as possi

ble. 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 proce dures. 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 chemica l 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

pro duction 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 report s.

Use Information

Column (1)

- Identify each possible category of use of the chemical substance by describing its function and appli

cation. "Function" is related to the inherent physical and chemical properties of the substance, (e.g., degreaser,

catal yst, 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 cat egories 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 th e 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 dist ributed from your site neat, enter N/A for Not Applicable.

For example:

Formulated

Product as Percent of Chemi

Category of Use Manufactured cal Sub stance

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 site

limited. 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 wa rehouses at the site. An example would be an intermediate that is further

reacted on

- site to produce a chemical product.

Industria l: The chemical substances or products containing the substance are used only at the site of other manufac

turers or processo rs, e.g., textile dyeing, paint formulation,

use of a resin to manufacture an article.

Commercia l: The chemical substances or products containing the substance are used only by a commercial enterprise providing a consumer service, e.g., use by com

m ercial dry cleaning establishments, use by painting contractors, or use by roofers in commercial building

construction.

Consume r: The chemical substances or products containing the substance are used by private individuals in or around a residence, or during re creation, or for any other personal use or enjoyment, e.g., automotive polish, dyed wearing apparel,
household cleaners, etc.

Column s (

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 p rotective 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

l oading, changing filters, and cleaning equipment.

Activities must be described even if workers wear protective equipment or clothing. (Recommended protect

tive 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 maxim um 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 descripti on 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

for m. Clearly identify the attachment and the section to

which it relates. Number consecutively the pages of the

attachments. E nter the total number of page s 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 claim ing 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 suggesti ons 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 addre ss. The

EPA Form 7710

- 51 actual information or form should be submitted in

a ccordance with the instructions accompanying the information or form, specified in the corresponding regulation.