U.S. ENVIRONMENTAL PROTEC~ION AGENCY 

&EPA PREMANUFACTURE 

'i NOTICE .; 

Date of receipt 

Company Sanitized 

( .. , 

-'I 

FOR NEW CHEMICAL SUBSTANCES 

-- r --a--

in the Premanufactu.re Notice 

GENERAL INSTRUCfiONS ' " l'~·liK 

• You must reo vide all infonnalion requested Ia lhia foi'Dllo Ike extent that it Ia known to or reasonably ucertain.able by you. Make re.uonable estimates if you 

not h<~ve<~dual data. "-"'' w. • 'Before you complete lhla form, you should read lhe "Instructions M.mual for Premanufacture Notification" (the Instruction& Manual is <~Vall able from the Toxic 

Substances Control Ad ITSCA) Information Service by cillllng :Z02·554-1404, or fulng 202-554-5603). 

•If,. user fee has been remitted for this notice (40 CJlR 100.45), lndlc:ate in the boxes <~bove the TS-uRr fee identification number you have generated. 

Remember, your user fee ID number must also appear on your correSponding fee remittance. which is sent to: EPA, HQ Accounting Operations Branch (PM-26 ), 

P.O. 360399M.Piltab~h,PA 15251-6399, Attn. TSCA UterFee~.-,INf , •"' 

.~:'-'"~i ... 

Part 1- GENERAL INFORMATION ·~· 

You muat provide the currenUy correct Chemlc:al Abstracts (CA) Name of the 

new chemicillaubst.mce, even if you datm the Identity • confldeatlal,' .¥ou may 

authorize another person to aubmit chemlc:al Ideality infonnaUo .. /for f"u'i bui · 

your submission will not be complete ud the review will not bizltlil'Jl!qEP,t\:' 

recelvea thia information. A Jetter Ia aupport of your submiuloaahould ;f~ 

refei'E'nce your TS uaer fee identlflaUon number. You must aubmlt -... orijlnal 

<~nd two copies of thla notice including il1l teat d..U .If you claimed any · '··.·~\',;l 

information as confidential, a single sanitized copy must also be submitted. -" 

Part II- HUMAN EXPOSURE AND ENVIRONMENTAL RElEASE 

If there are several manuf.lldure, processing. or use operations to be desaibed in 

Part II, sections A and B of thl.a notice, reproduce the sections as needed. 

Part III- UST OF A TT AOiMENTS 

AHach addillonalaheeta if there Ia not enough sp..ce to answer a question fully. 

Label e..ch continuation sheet with the corresponding section huding. In Part 

III, list these attachments, any lesl dill" or other dillla and any optional 

information included in the notice. 

OPTIONAL INFORMATION 

. TEST DATA AND OTHER DATA 

You an: required to submit aU test d.at.a in your poueuion or control 

and to provide a deac:riptioll of aU other data known to or reMOnably 

ascertainable by you, If thue data a.ae mailed to the heillth and 

envlronment.al effects of the ma.nufadun!, prooeaaing. distribution 

in mmmesa, use, or dlspo&ill of the new chemlcillsubstance. Standard 

literalun! dtatlont may be aubmltted for data In the open adentific 

literalun!. Complete test dati <wriHeo In EOj~lishl not sqmmarles of dab. 

mut be subm!Hed if they do not apRfar in the ORfD l!tera&urc. You should 

dearly J~entlfy whether test data is on the substance or on an analog. Also, 

the chemlc:al composition of the tested materialahould be characterized. 

Following are ex;unples of lest dilla and other data. Data should be 

submitted according to the requirements of §720.50 of the Premanufacture 

NotlflgiJQI\ Rule (40 CFR P.otrt 720). 

li1l Test Data •Check Below any included In this notice) 

• Environmental fate d.Ua D Yes • Otherdata D Ye11 

• Heitlth effects datil D Yes lliak oil.!laeN menta 

• Environmental effects data D Yes Strudurel.actlvity relationshi 

You may include any information that you want EPA to consider In evilluillling 

the new aubstan('L On page 11 of lhla form, apace hu beeft provided for you to 

describe pollution prevention and recycling information you may have regarding 

the new substance. 

• Physlc.alJChemlcal Properties • ~ Yea T Hl data not lA the poliHH in 

So-called "binding" boxes are included throughout thla form for you to indicate 

your wiUingness to be bound to oert.ain atatemenls you make In lhi& notice, such 

as use, production volume, protective equipment ... Thla option Is intended to 

reduce del.aya that routinely acmmp.any the development of consent orden or 

Significant New Use Rules. Excepllll the case of exemption appllatlona (auch as 

TMEA, L VE, LOREX) where certa.la Information provided in such notification Is 

bindl~g on the submitter when the Agency approves the exemption application, 

checking a binding box In thls notice .dw::l...wU by itaelf prohibit the aubmiHer 

from I.Uer devl.Uing from the Information (except chemk:itlldentity) reported In 

the form. 

CONFIDENTIALITY CLAIMS 

You may d.tlm .any Information In this notice u conftdentl.al. To auert a clalm 

on the fol"DD. ma.rk 00 the oonfldentl.al box nextlo the lnformilllon that you claim 

as confidential. To assert a claim in an attachment, drcle or br<~cket the 

information you claim a confidential. U you claim lpfgnnat!gn in the ngtic;e 11 confidential you must ,alao proyidc a s.a,nitlzed version of the notice Undyifjq 

iltacbments). For additlonitlinslrudlona on claiming infonnalion as 

confidential, read the Instructions Manuitl. 

~k (X) If any lnformilllon In this notice Is claimed as confidential. 

EPA FORM 7710-25 (Rev. !>-95) 

or control of the 1ubmitter 

•A physical and chemlcill properties worksheet laloc.1led on the l•l page 

of this form. 

TYPE OF NOTICE (Check Only One) 

~ PMN (Pre~anufacture Notice) 

0 lNTERMEDIA TE PMN (submitted in sequence with finai product 

PMN) 

0 SNUN (Signiflc:ant New Uae Notice) 

D TMEA CTe.t Muketing Exemption Apptlc:.ation) 

0 L VE (Low Volume bemptioa) • 40 CFR 123.50 (c)(l) 

D LOREX (Low Rele.ase/Low Expoaure Exemption) 0 723.50(c)(2) 

0 L VE Modlfiatlon 0 LOREX Modification 

IS TillS A CONSOLIDATED PMNl D Yea 

I of chemlc.ah; 

(Prenotice Communication I required, enter I on p,age 3) 

I 

I , 

~ 

i . 

. 

. 

(_ 

Replaces previous editions of EPA Form 7710.25 

J 

:_;; ~? 

*- -~; c-·-:;' 

··-. , __ 'j 
Public reporting burden for this collection of information is estimated to average 110 hours per response, including time for reviewing instructiom' 

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send 

comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for redud.ng this burden, 

to Cllief, Information Policy Branch, PM·223, U.S. Environmental Protection Agency, 401 M. St., S.W., Washington, D.C. 20460; and to the Office< 

Management and Buc!get, Paperwork Reduction Act (2070-0012), Washington, D.C. 20503. 

CERTIFICATION 

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

1. The company named in Part I, section A, subsection la of this notice form intends to manufacture or import for a 

commercial purpose, other than in small quantities solely for research and development, 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. 

3. I am submitting with this notice all test data in my possession or control and a description of all other data known to 

or reasonably ascertainable by me as required by §720.50 of the Premanufacture Notification Rule. 

Additional Certification Statements: 

If you are submitting a PMN, Intermediate PMN, Consolidated PMN, or SNUN, check the following user fee certification 

statement that applies: 

J8[ The Company named in Part t Section A has remitted the fee of $2500 specified in 40 CFR 700.45 (b), or 

0 The Company named in Part I, Section A has remitted the fee of $1000 for an Intermediate PMN (defined @ 40 CFR 700.4 ) in 

accordance with 40 CFR 700.45(b), or 

0 The Company named in Part I, Section A is a small business concern under 40 CFR 700.43 and has remitted 

a fee of $100 in accordance with 40 CFR 700.45 (b). 

If you are submitting a low volume exemption (L VE) application in accordance with 40 CFR 723.50 (c) (1) or a Low 

release and low exposure exemption (LoREX) application in accordance with 40 CFR 723.50 (c) (2), check the following 

certification statements: 

D The manufacturer submitting this notice intends to manufacture or import the new chemical substance for 

commercial purposes, other than in small quantities solely for research and development, under the terms 

of 40 CFR 723.50. 

0 The manufacturer is familiar with the terms of this section and will comply with those terms; and 

0 The new chemical substance for which the notice is submitted meets all applicable exemption conditions. 

0 If this application is for an L VEin accordance with 40 CFR 723.50 (c}(l), the manufacturer intends to commence 

manufacture of the exempted substance for commercial purposes within 1 year of the date of the expiration of the 

30 day review period. 

The accuracy of the statements you make in this notice should reflect your best prediction of the anticipated facts regarding the chemical 

substance described herein. Any knowing and willful misinterpretation is subject to criminal penalty pwsuant to 18 USC 1001. 

Signature and title of Authorized Official (Original Signature Required) Date 

Signature of agent • (if applicable) Date 

FORM EPA 7710-25 (Rev. S..95) Page2 

Confidenti• 1 
la. Person 

Submitting 

Notice 

(in U.S.) 

b. Agent (if 

applicable) 

Part I-- GENERAL INFORMATION 

Mailing address (number and street) 

Gty, State, ZIP Code 

Name of authorized official 

Company 

Mailing address (number and street) 

Oty, State, ZIP Code 

Telephone 

c. If you are submitting this notice as part of a joint submission, mark (X) this box. --------------------

Joint Name of authorized official 

Submitter 

(if applicable) 

Company 

Mailing address (number and street) 

2. Technical 

Contact 

(in U.S.) 

City, State, ZIP Code 

Name 

Company 

Mailing address (number and street) 

City, State, ZIP Code 

3. If you have had a prenotice communication (PC) concerning this notice 

and EPA assigned a PC Number to the notice, enter the number. 

4. If you previously submitted an exemption application for the chemical 

substance covered by this notice, enter the exemption number assigned 

by EPA. If you previously submitted a PMN for this substance enter the 

PMN number assigned by EPA (i.e. withdrawn or incomplete). 

If you have submitted a notice of Bona fide intent to manufacture or 

import for the chemical substance covered by this notice, enter the 

notice number assigned by EPA. > 

Type of Notice- Mark (X) 

FORM EPA 7710-25 (Rev. 5-95) 

1. D 

D 

Manufacture 

Only 

Binding Option 

Mark {x) 

Page3 

Position 

Telephone 

Position 

Telephone 1 

I 

2. 0 

0 

Import 

Only 

Mark (X) 

if none 

Mark (X) 

if none 

Mark (X) 

if none 

BindingOption 

Mark (x) 

3. E2?' Both 
Part I-- GENERAL INFORMATION --CONTINUED 

:Section B --CHEMICAL IDENTITY 

INFORMATION: 

You must provide a currently correct Chemical Abstracts name of the substance 

based on the ninth Collective Index (9CI) of CA nomenclature rules and 

conventions. 

Mark (X) the ··confidential" box next to anv item you claim as confidential. 

Complete either item t (Class I or 2 substances) or 2 (Polymers) as appropriate. Complete all other items. 

If another person will submit chemical identity information for you (lor either item I or 2), mark (X) the box at the right 

Identify the name, company, and address of that person in a continuation sheet. D 

1'. Class 1 or 2 chemical substances (tor definitions of class I and class 2 substances, see the Instructions Manual) 

a. Class of substance -- Mark (X) I D Class I or 2 Octass 2 

b. Chemical name (Currently correct Chemical Abstracts (CA) Name that is consistent with TSCA Inventory listings for similar 

substances. For Class 1 substances a CA Index Name must be provided. For Class 2 substances either a CA Index Name orCA 

Prdcrn.:d Name must be provided. whichever is appropriate based on CA 9Cinomenclature rules and conventions.). 

c. Please identi(y which method you used to develop or obtain the specilied chemical information reported in this notice: 

(check one). 

C2J Method I (CAS Inventory Expert Service- a copy of the Identification 

report obtained fi·om the CAS Inventory Expert Service must be 

submitted as an attachment to this notice) 

d. rvtolecular Formula and CAS Registry Number (if a number already exists for the substance) 

I 

Method 2 (Other Source) 

e. For a class I substance. provide a compkte and correct chemical structure diagram. For a class 2 substance -- (I) List the immediate 

.precursor substances with their respective CAS Registry Numbers. (2) Describe the nature of the reaction or process. (3) Indicate the 

range or composition and the typical composition (where appropriat~.:). (4) Provide a correct representative or partial chemical structure 

!diag~<un as complete as can be known, if one can be reasonably ascertained. 

0 Mark (X) this box if you attach a continuation sheet. 

~-ORM EPA 7710-25 (Rev. 5-95) Page 4 

Confidential 

X 

X 

X 

X 

X 
Part I-- GENERAL INFORI\1ATION --Continued 

Section B --CHEMICAL IDENTITY INFORMATION-- Continued 

2. Polymers (For a definition of polymer, see the Instructions Manual.) Confidential 

a. Indicate the number-average weight of the lowest molecular weight composition of the polymer you intend to manufacture. 

Indicate maximum weight percent of low molecular weight species (not including residual monomers, reactants, or solvents) below 

500 and below 1000 absolute molecular weight of that composition. 

Describe thl.! methods of measurement or the basis for your estimates: GPCO Other 0: Specify: Calculated 

i) lowest number average molecular weight 

ii) maximum weight% below 500 mokcular weight 

iii) maximum weight% below 1000 molecular weight 

D ivlark (X) this box if you attach a continuation sheet 

b. You must make separate confidentiality claims for monomer or other reactant identity, composition information, and residual information. 

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

(I) - Provide the specific chemical name and CAS Registry Numbl.!r (9f a numba exists) of each monomer or other reactant used in thl.! 

manufactur~ ofthe polymer. 

(2)- l\lark (X) this column if entry in column ( 1) is conlidentiaL 

{3) - Indicate the typical weight percent of each monomer or other reactant in the polymer. 

( 4)- Mark (X) the identity column if you want a monomer or other reactant used at two weight percent or kss to be listed as part of the 

polymer description on the TSCA Chemical Substance Inventory. 

(5) - Mark (X) this column if entries in columns (3) and (4) arc confidential. 

(6) Indicate the maximum weight percent of each monomer or other reactant that may be present as a residual in the polymer as 

manufactured for commercial purposes. 

(7)- Mark (X) this column if entry in column (6) is confidential. 

i\tonomcr or other reactant and CAS H.cgistry Number Confi- Typical Identity Conli- :\laximum Conti-

(1) dcntial Composition i\lark (X) dential Residual dential 

(2) (3) (-') (5) (6) (7) 

% % 

% % 

% % 

% % 

% % 

0 Mark (X) this box if you attach a continuation sheet. 

c. Pkase identitY which method used to (kvdop or obtain the spccilkd chemical idl.!ntity information reported in this notice. (check one). 

0 Method I {CAS Inventory Expert Service- a copy of the idl.!ntilication report 0 Method 1 (other source) 

obtained from the CAS Inventory Expert s~rvic~ must be submitted as ·. 

an attachment to this notice) 

d. The currently correct Chemical Abstracts (CA) name for the polyml.!r that is consistent \\ith TSCA Inventory listings for similar 

poI ymers. 

' 

c. Pnn·ide a correct representation or partial chemical structure diagram. as complete as can be known, if one can be reasonably 

asccrtain~d. 

D Mark (X) this box ifyou attach a continuation shc~l. 

FORM EPA 7710-25 (Rev. 5-95) Page 5 
Part I-- GENERAL INFORMATION --Continued 

Section B -- CHEMICAL IDENTITY INFORMATION-- Continued 

3. Impurities 

(a) ..• Identify each impurity that may be reasonably anticipated to be present in the d1emical substance as manufactured for commercial purposes. 

Provide the CAS Registry Number if available. If they are unidentified inlJurities, enter ''unidentified." 

(b)·· Estimate the maximum weight% of each impurity. If there are unidentified inlJurities, estimate their total weight%. 

Impurity and CAS Registry Number Maximum Conti· 

(a) percent dential 

{b) 

X 

X 

X 

X 

X 

X 

D Mark (X) this box if you attach a continuation sheet 

4. Synonyms·· Enter Conti· 

dential 

X 

D rvlark (X) this box if you attach a continuation sheet 

5. Trade ickntitication ·· X 

D Mark {X) this box ifyou attach a continuation sheet 

6. Generic chemical name·· If you claim chemical identity as confidential. you must provide a generic chemical name for your substance 

that reveal s the specific chemical identity of the new chemical substam:c to the maximum extent possible. 

Refer to the TSCA Chemical Substance Inventory. 1985 Edition, Appendix B for guidanc~ on developing 

generic names. 

Acrylate Ester 

D Mark (X) this box if you attach a continuation sheet 

7. Byproducls -· 0-:scribl.! any byproducts from the manu!l1ctur~. proc~ssing. usc. or disposal of the new chemical substance. Provide the CAS 

Rc!l.istrv Number if availabk. 

Byproduct CAS Registry Number Conli· 

(I) (2) dcntial 

X 

X 

X 

X 

X 

X 

X 

X 

D Mark (X) this box if you attach a continuation sheet 

FORM EPA 7710-25 (Rev. 5·95) Page 6 
Part I --GENERAL INFORMATION-- Continued 

Section C --PRODUCTION, IMPORT, AND USE INFORMATION: 

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

I. Production volume- Estimate the maximum production volume during the first 12 months of production. Also estimate the maximum 

production volume for any consecutive 12 month period during the first three years of production. Estimates should be on 100% new chemical 

substances basis. For Low Volume Exemption application, if you choose to have your notice reviewed at a lower production volume than 

I 0,000 kg/yr., specify the volume and mark (x) in the binding box. If granted, you are bound to this volume. 

Maximum first 12-month production (kg/yr) Maximum 12-month production (kg/yr) Conti- Binding 

( 100% new chemical substance basis) ( 100% new chemical substance basis) dential Option 

Mark (X) 

X 

2. Use Inf'ormation- 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 new substance, and other use information. Mark (X) the '"Confidential" Box next to any item you 

claim as confidential. 

a. (I) --Describe each intended category of use of the new chemical substance by function and application. 

(2) --l'vlark (X) this column if entry in column (I) is confidential business information (CBI). 

(3) --Indicate your willingness to have the information provided in column (I) binding. 

( 4) --Estimate the percent of total production for the tirst three years devoted to each category of usc. 

(5) --Mark (X) this column if entry in column ( 4) is confidential business information (CBI). 

(6) --Estimate the percent ofthe new substance as formulated in mixtures. suspensions, emulsions, solutions, or gels as manufactured for 

commercial purposes at sites under your control associated \vith each category of use. 

(7) --Mark (X) this column if entry in column (6) is confidential business information (CBI). 

(8) --Indicate% of product volume expected for the listed .. use"' sectors. Mark more than one box if appropriate. Mark (X) to 

indicate your willingness to have the use type provided in (8) binding. 

(9) --Mark (X) this column if entry(ies) in column (8) is (are) confidential business information (CBI). 

Category of use (I) CBI Binding Produc- CBI %in CBI 0/ 

/0 of substance expected per use CBI 

(b) functional and application. i.e .. a dispersive dye Option lion'% Form- (8) ll)r finishing polyester fibers) Mark (x) ulation 

(2) (3) (4) (5) (6) (7) Site- Con- Indus- Com- Binding (9) limitt:d sumer• trial mercia! Option 

X X X X 

X X X X 

*!!"you have identified a ··consumer'" usc. please provide on a continuation sheet a detailed description of the use(s) of this chemical substance in 

consumer: product~. In additi_on in~lude estimates of the concentration of the ne\\ chemical substance as expected in consumer products and describe 

the chemrcal reacttons by \\hJch thts substance loses its identity in the consumer product. 

D Mark (x) this box ifyou attach a continuation sheet. 

b. Generic If you claim any category o~· use description in subsection 2a as confidentiaL enter a generic description of that usc category. Read the Instruct tOns Manual for examples of generic use descriptions. 

description 

Monomer in radiation cured coatings and inks 

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

3. Ha~ar? Info:matiOJ_1-In~lude in th~ notice a copy of the reasonable facsimile of any hazard warning statement, label, material safety data sheet, or Binding other mtormation \\htch will be provided to any person who is reasonably likely to be exposed to this substance reoa d. t t" · • • • . . · ' :o r mg pro ec tve equtpment or Option practtces tor the sate handlmg, transport, usc, or disposal of the new substance. List in part III hazard information you include. Mark (X) L8J Mark (x) this box if you attach hazard information. D 

FORM EPA 7710-25 (Rev. 5-95) Page 7 
Part II -- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE 

Section A-- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER: Mark (X) the "Confidential" box next to 

any item you claim as confidential. 

Compkt~ s~ction A for ~ach typ~ of manufacture, processing. or use operation involving the ne\v chemical substance at industrial sites you control. 

lmport<:.:rs do not have to compkte this section for operations outside the U.S.; however, you may still have reporting requirements if there are further 

industrial processing or use operations after import. You must describe these operations. See instructions manual. 

I. Opcratien description Contia. Identify-- Enter the identity of the site at which the operation will occur. dential 

Name X 

Site Address (number and street) 

City. County, State. ZIP Code 

If the same operation will occur at more than one site. enter the number of sites. Identify the 

Additional sites on a continuation sheet. and if any of the sites have significantly different 

Production rates or operations. include all the information requested in this section for those 

Sites as attachments. 

D Mark (X) this box if you attach a continuation sheet. 

b. Type--

Mark (X) D Manufacturing D Processing 

c. Amount and Duration -- Complete I or 2 as appropriate 

I Batch 

2. Continuous 

Maximum kg/batch ( 100".;, nc'' chemical Hours/batch 

substam:c) 

Maximum kg/day !IOO"o new d1cmical Hours/day 

substaiH.:c) 

D Use 

d. Process description: D Mark (X) to indicate your willingness to have your process description binding. 

#of sites 

Batches/year 

Days/year 

(I l Di~gra~1~ the major unit ~peration steps and chemical conversions. Include interim storage and transport containers (specify-e.g. 5 gallon 

palls.)) gallon drum. rml car, tank truck. etc.) 

(2) Prov.ide the id~ntity. th~ appropria~e wei¥ht (by kg/day or kg/hatch on a 100% new chemical substance basis), and entry point of all 

startmg mater.wls and Iced stocks (mcludmg reactants. solvents. and catalysts. etc.). and of all products. recycle streams. and wastes. 

Include cleanmg chemicals (note frequency if not used daily or per batch). 

(3) Identify by number the points of release. including small or intermittent releases. to the environment ofthe new chemical substances. 

FORM EPA 7710-25 (Re\. 5-95) Page 8 

' 

.·. 

.. 

X 

X 

X 

X 
Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued 

Section A INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER-- Continued 

2. Occupational Exposure •• You must make separate con lidentiality claims for the description of worker activity; physical fo.rm of the _new ~hemical 

substance. number of workers exposed, and duration of activity. Mark (x) the .. Confidential" box next to any ttem you clatm as conhdenttal. 

{ 1 )--Describe the activities (i.e. bag dumping, tote filling, unlo<rling drums, sampling. cleaning. etc.) in which workers may be exposed to the 

substance. 

(2)--Mark (X) this column if entry in column (I) is confidential business information (CBI). 

(3)--Describe any protective equipment and engineering cnntrols used to p·otect workers. 

(4) and (6)-- Indicate your willingness to havr.:: the information provided in column (3) or (5) bind.ing. . . . 

(5)--lndicate the physical form(s) and% new chemical substance (if in mixture) of the new d1etmcal substance at the ttme of exposure (t.e., solld: 

crystal, granule, powder, or dust) and %new chemical substance (if in mixture). 

(7)--tvtark (X) this column if entry in column {5) is confidential business information (CBI). 

(8)--Estimate the maximum number of workers involved in each activity for all sites combined. 

(9)--Mark (X) this column if entry in column {8) is confidential businc.:ss information {CBI). 

(I 0) and (II )--Estimate the maximum duration of the activity for any worker in hours per day and days per year. 

(12)--Mark (X) this column if entry in columns (10) and (II) arc confidential business information (CBI). 

Worker activity CBI Protective Equipment/ Binding Physical torm(s Binding CBI #of CBI Maximum duration em 

(i.e., bag dumping, tilling Engineering Controls Option and% new Option Workt:rs Hr/day Days/yr 

drums) Mark(x) substance Mark (x Exposed 

( I ) (2) (3) (4) (5) (6) (7) (8) (9) (10) (II) (12) 

X X X X 

X X X x. 

X X X X 

X X X X 

0 tvlark (X) this box if you attach a continuation sheet. 

3. Environmental Release and Disposal-- You must make separate conlidentiality claims for the release number and the amount of the new chemical 

substance released and other release and disposal information. Mark (x) the "Conlidc.:ntial" box next to each item you claim as confidential. 

(I)-- Enter the number of each release point iclentitkd in the process description. part II. section A. subsection I d(3 ). 

(2)--Estimate tht: amount of the new substance released (a) directly to the ern-ironment or (b) into control technology (in kg/day or kg/batch). 

(3 )--tvlark (X) this column in entries in columns { 1) and (2) arc conlidcntial business information (CBI). 

{-t)--l<.kntif~: the media (stack air. fugitive air (optional-s!.!e Instruction tv1anual). surface water. on-sit!.! or off-site land or incineration. POT\\', or 

other (specify) to which the new substance will be released fi·om that release point. 

(5 )--a. Describe control technology. if any. and control efficiency that will be used to limit the release of the new substance to the environment. 

For releases disposed on land, characterize the disposal method and state whether it is approved for disposal of RCRA hazardous waste. 

On a continuation sheeL for each site describe any additional disposal methods that \viii be used and whether the waste is subject to 

secondary or tertiary on-site treatment. b. Estimate the amount released to the environment after control technology (in kg/day). 

(6)--ivlark {X) this column if entries in columns (..J.) and (5) are confidential business information (CBI). 

(7)--ldentify the tkstination(s) or rekascs to water. Please supply NPDES (National Pollutant Discharge Elimination System) numbers for direct 

dischargers or NJ>DES numbers of the POT\\' (Publicly Owned \Vater Treatment Works). !\lark (X) if the POTW name or NPDES #is 

contidential business information {CBI ). 

Rckasc Amount of nc\\ CBI Media of Control tcchnolo£!.\' and eflicicncv (you may wish to optionally attach efficiency data) CI31 

Number substance released release c g. Binding 

slack air Mark 

(I) (2a) (2b) (3) (4) (5a) (x) (5b) (6) 

X X 

X X 

X X 

X X 

( 7) Mark (x) the D POTW provide names bclmv: CI31 0 Navigable D Other-specify provide NPDES # CBI 

destinations or Waterway 

releases to water t--

0 Mark (X) this box if you attach a continuation sheet. 

FORM EPA 7710-25 (Rev. 5-95) Pag~:9 
Part II --HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued 

Section B -- INDUSTRIAL SITES CONTROLLED BY OTHERS 

Complete section B for typical processing use operations involving the new chemical substance at sites you do not control. Optional for typical 

manLifacturing or processing operations involving the new chemical substance at sites outside the U.S. that you do not control- see Instructions 

Manual. Complete a separate section B for each type of processing, or usc operation involving the new chemical substance. Ifthe same operation is 

performed at more than one site describe the typical operation common to these sites. Identify additional sites on a continuation sheet. Optional for 

sites outside the United States. - See Instructions Manual. 

· t. Operation Description- To claim information in this section as confidential, circle or bracket the specific information that you claim as confidential. 

(I) -- Diagram the major unit operation steps and chemical conversions, including interim storage and transport containers (specify- 5 gallon pails, 

55 gallon drums, rail cars, tank trucks, etc.). On the diagram, identil)' by letter and brielly describe each worker activity. 

(2) -- Provide the identity, the approximate weight (by kg/day or kg/batch, I 00% ne\v chemical substance basis), and entry point of all feedstocks 

(including reactants solvents and catalysts, etc.) and of all products. recycle streams, and wastes. Include cleaning chemicals (note frequency 

if not used daily or per batch). 

(3) -- Identify by number the points of release, including small or intermittent releases. to the environment of the new chemical substance. 

( 4)- Please enter the# of sites (remember to identity the location of these on a continuation sheet. 

Enter# of sites __ _ 

[g) tvlark (X) this box if you attach a continuation sheet. 

2. Worker Exposure I Environmental Release 

(I)-- From the diagram above. provide the letter for each \vorker activity. Complete 2- 8 for each worker activity described. 

(2) --Estimate the number of workers exposed for all sites combined. 

( 4) -- Estimate the typical duration of exposure per \vorker in (a) hours per day and (b) days per year. 

((l) --Describe physical form of exposure and% new chemical substance (if in mixture), and any protective equipment and engineering controls, if 

any used to protect workers. 

{7) -- Estimate the percent of the new substance as formulated when packaged or used as a final product. 

(9) --From the process diagram above. enter the number of each release point. Complete 9-13 for each release point identified 

1 (10) --Estimate the amount of the new chemical substance release (a) directly to the environment or (b) into control technology to the en\ironmcnt 

(in kg/day or kg/batch). 

( 12) --Describe media of release (stack air, fugitive air, (optional- sec Instructions Manual), surface water, on-site or otT-site land or incineration 

POTW, or other (specify)) and control technology. if any. that will be used to limit the release of the new substance to the environment. ' 

( 14) --Identify byproducts which may result from the operation. 

(3 ). (5). (8). (II). ( 13) and ( 15) --Mark (X) this column if any of the proceeding entries are confidential business information (CBI). 

Letter # of CBI Duration CBI Protective Equip. I % in CBI Release Amount of CBI Control CBI 

of Workers of Engineering Controls I Form- Number New Technology 

Act- Exposed Exposure Physical Form and % ulation Substance 1 iYity ne\\' substance Released 

(I) (2) (3) (4a) (4b) (5) (6) (7) (8) (9) (lOa) (lOb) (II) (12) (13) 

( 14) Byproducts: ( 15) 

D Mark (X) this box ifyou attach a continuation sheet 

fORI\! EPA 7710-25 (Rev. 5-95) Page 10 
OPTIONAL POLLUTION PREVENTION INFORMATION 

To claim information in this section as confidential circle or bracket the specific information that you claim as confidential. 

In this section you may provide information not reported elsewhere in this form regarding your 

efforts to reduce or n1inin1ize potential risks associated with activities surrounding 

n1anufacturing, processing, use and disposal of the PMN substance. Please include new 

information pertinent to pollution prevention, including source reduction, recycling activities 

and safer processes or products available due to the new chemical substance. Source reduction 

includes the reduction in the an1ount or toxicity of chen1ical wastes by technological 

n1odification, process and procedure n1odification, product reformulation, raw materials 

substitutions, and/or inventory control. Recycling refers to the reclamation of useful chemical 

discharges, or land disposal. Descriptions of pollution prevention, source reduction and 

recycling should en1phasize potential risk reduction subsequent to con1pliance with existing 

regulatory requiretnents and can be either quantitative or qualitative. The EPA is interested in 

this infonnation to assess overall net reductions in toxicity or environn1ental releases and 

exposures, not the shifting of risks to other environmental media or non-environmental areas 

(e.g., occupational or consumer exposure). In addition, inforn1ation on the relative cost or 

perfonnance characteristics f the PMN substance to potential alternatives may be provided. 

All information provided in this section will be taken into consideration during the review 

o f this substance. See Instructions Manual and Pollution Prevention Guidance manual for 

guidance and examples. 

Describe the expected net benefits, such as ( 1) an overall reduction in risk to human health or the environment; (2) a reduction in 

the volume manufactured; (3) a reduction in the generation of waste materials through recycling, source reduction or other 

means; ( 4) a reduction in potential toxicity or human exposure and /or environmental release; (5) and increase in product 

performance, a decrease in the cost of production and /or improved operation efficiency of the new chemical substance in 

comparison to existing chemical substance used in similar applications; or (6) the extent to which the new chemical substance 

may be a substitute for an existing substance that poses a greater overall risk to human health or the environment. 

0 Mark (X) this box if you attach a continuation sheet. 

rORM EPA 7710-25 (Rev. 5-95) Page II 
Part III-- LIST OF ATTACHMENTS 

Attach continuation sheets for sections of the form and test data and other data (including physical I chemical properties and structure I 

activity information), and optional information after this page. Clearly identify the attachment and the section of the form towhich it 

relates, if appropriate. Number consecutively the pages of the attachments. In the column below, enter the inclusive pagenumbers of 

each attachment. 

Mark (X) the "Confidential" box next to any attachment name you claim as confidential. Read the Instructions Manual forguidance on 

how to claim any information in an attachment as confidential. You must include with the sanitized copy of the noticeform a sanitized 

copy of any attachment in which you claim information as confidential. 

Attachment name Attachment Conftpage number(s) dential 

X 

X 

X 

X 

X 

X 

X 

X 

X 

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

FORI\! EPA 7710-25 (Rev. 5-95) Page 12 
PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET 

To assist in EPA's revi.-:w of physical and chemical properties data, please complete the following worksheet for data you provide 

and include it in the notice. Identify the property measured, the page of the notice on which the property appears, the value 

ofthe property, the units in which the property is measured (as necessary), and whether or not the property is claimed as 

confidential. The physical state of the neat substance should be provided. These measured properties should be for the neat (100% 

pure) chemical substance. Properties that are measured for mixtures or formulations should be so noted (% PMN substance in_). You 

arc not required to submit this worksheet; however, EPA strongly recommends that you do so, as it will simplify review and ensure 

that confidential information is properly protected. You should submit this worksheet as a supplement to your submission oftest 

data. This worksheet is not a substitute for submission of test data. 

Property Mark (X) if Page Value Measured Confiprovided number or Estimate dcntial 

(a) (b) (c) (MorE) 

Mark (x) 

(d) 

Physical state of neat substance _(s)_(l) __ (g) X 

Vapor pressure@ Temperature oc torr 

Dc1isity I relative density glcm3 X 

Solubility 

@Temperature 

Solvent giL 

Solubility in water@ Temperature g/L X 

Mdting temperature oc 

Boiling I sublimation temperature @ torr pressure 

Spectra X 

Dissociation constant 

Particle size distribution 

Octanol I \\akr partition coefficient 

I knr{s Law constant 

Volatilization from water 

Volatilization from soil 

pH @ concentration __ 

Flammability 

Explodability 

Adsorption I coefficient 

Other- specify X 

X 

FORM EPA 7710-25 (Rev. 5-95) Page 13 
Page 14 
Page 15 
Page 16 
Page 17 
Page 18 
Page 19 
Page 20 
Page 21 
Page 22 
Page 23 
Page 24 
Page 25 
Page 26 
Page 27 
Page 28 
Page 29 
Page 30 
Page 31 
Page 32 
Page 33 
Page 34 
Page 35 
Page 36