Attachment D - Currently Approved PMN Form

Form Approved. O.M.B. No. 2070-0012. Approval Expires 07-31-04

U.S. ENVIRONMENTAL PROTECTION AGENCY

AGENCY USE ONLY
Date of receipt

PREMANUFACTURE
NOTICE
FOR NEW CHEMICAL SUBSTANCES
When
completed
send this
form to

If sending by courier:
If sending by US Mail:
TS7407M DCO
TS7407M DCO
TSCA CBI OPPTS EPA
TSCA CBIC
Room 6428
OPPTS-EPA
1200 Pennsylvania Ave, NW 1201 Constitution Ave,NW
Washington, DC 20004
Washington, DC 20460

Enter the total number of pages
in the Premanufacture Notice

Document control number

GENERAL INSTRUCTIONS
•
•
•

EPA case number

TS -

You must provide all information requested in this form to the extent that it is known to or reasonably ascertainable by you. Make reasonable estimates if you do
not have actual data.
Before you complete this form, you should read the “Instructions Manual for Premanufacture Notification” (the Instructions Manual is available from the Toxic
Substances Control Act (TSCA) Information Service by calling 202-554-1404, or faxing 202-554-5603).
If a user fee has been remitted for this notice (40 CFR 700.45), indicate in the boxes above the TS-user 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, Washington Financial Management Center (3303), P.O.
360399M, Pittsburgh, PA 15251-6399, Attn. TSCA User fee.

Part I  GENERAL INFORMATION

TEST DATA AND OTHER DATA

You must provide the currently correct Chemical Abstracts (CA) Name of the new
chemical substance, even if you claim the identity as confidential. You may authorize
another person to submit chemical identity information for you, but your submission will
not be complete and the review will not begin until EPA receives this information. A letter
in support of your submission should reference your TS user fee identification number.
You must submit an original and two copies of this notice including all test data. If you
claimed any information as confidential, a single sanitized copy must also be submitted.

If there are several manufacture, processing, or use operations to be described in Part II,
sections A and B of this notice, reproduce the sections as needed.

You are required to submit all test data in your possession or control and to
provide a description of all other data known to or reasonably ascertainable by
you, if these data are related to the health and environmental effects on the
manufacture, processing, distribution in commerce, use, or disposal of the new
chemical substance. Standard literature citations may be submitted for data in the
open scientific literature. Complete test data (written in English), not summaries
of data, must be submitted if they do not appear in the open literature. You should
clearly identify whether test data is on the substance or on an analog. Also, the
chemical composition of the tested material should be characterized. Following
are examples of test data and other data. Data should be submitted according to
the requirements of §720.50 of the Premanufacture Notification Rule (40 CFR
Part 720).

Part III  LIST OF ATTACHMENTS

Test Data

Attach additional sheets if there is not enough space to answer a question fully. Label each
continuation sheet with the corresponding section heading. In Part III, list these
attachments, any test data or other data and any optional information included in the notice.

•

Environmental fate data

Yes

•

Health effects data

Yes

Risk assessments

•

Environmental effects data

Yes

Structure/activity relationships

OPTIONAL INFORMATION

•

Physical/Chemical Properties*

Yes

Test data not in the possession
or control of the submitter

You may include any information that you want EPA to consider in evaluating the new
substance. On page 11 of this form, space has been provided for you to describe
pollution prevention and recycling information you may have regarding the new substance.

*

A physical and chemical properties worksheet is located on the last page of this form.

Part II  HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE

(Check Below any included in this notice)

TYPE OF NOTICE
So-called “binding” boxes are included throughout this form for you to indicate your
willingness to be bound to certain statements you make in this section, such as use,
production volume, protective equipment . . . This option is intended to reduce delays that
routinely accompany the development of consent orders or Significant New Use Rules.
Except in the case of exemption applications (such as TMEA, LVE, LOREX) where
certain information provided in such notification is binding on the submitter when the
Agency approves the exemption application, checking a binding box in this notice does not
by itself prohibit the submitter from later deviating from the information (except chemical
identity) reported in the form.

• Other data

Yes

(Check Only One)

PMN (Premanufacture Notice)
INTERMEDIATE PMN (submitted in sequence with final product PMN)
SNUN (Significant New Use Notice)
TMEA (Test Marketing Exemption Application)

CONFIDENTIALITY CLAIMS
You may claim any information in this notice 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. If you claim information in the notices as confidential, you must also provide
a sanitized version of the notice, (including attachments). For additional instructions on
claiming information as confidential, read the Instructions Manual.

LVE (Low Volume Exemption) @ 40 CFR 723.50(c)(1)
LOREX (Low Release/Low Exposure Exemption) @ 40 CFR 723.50(c)(2)
LVE Modification

LOREX Modification

IS THIS A CONSOLIDATED PMN?
Mark (x) if any information in this notice is claimed as confidential.

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

Yes

1

# of chemicals or polymers
(Prenotice Communication # required, enter # on page 3)

Replaces previous editions of EPA Form 7710-25.

Public reporting burden for this collection of information is estimated to average 105.5 hours per response, including 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 the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Director, Collection Strategies Division (2822), U.S. Environmental Protection Agency, 1200 Pennsylvania Ave., N.W.,
Washington, D.C. 20460; and to the Office of Management and Budget, Paperwork Reduction Act (2070-0012), Washington, D.C. 20503.

CERTIFICATION -- A Printed copy of this signature page, with original signature, must be submitted
I certify that to the best of my knowledge and belief:
1.

The company named in Part I, section A, subsection 1a 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:
The Company named in Part I, Section A has remitted the fee of $2500 specified in 40 CFR 700.45(b), or
The Company named in Part I, Section A has remitted the fee of $1000 for an Intermediate PMN (defined @ 40 CFR
700.43) in accordance with 40 CFR 700.45(b), or
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 (LVE) 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:
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.
The manufacturer is familiar with the terms of this section and will comply with those terms; and
The new chemical substance for which the notice is submitted meets all applicable exemption conditions.
If this application is for an LVE in accordance with 40 CFR 723.50(c)(1), 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 pursuant to 18 USC 1001.
Signature and title of Authorized Official (Original Signature Required)
Date

Signature of agent - (if applicable)

Date

Do you want these signatures to be digital?

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

Page 2

Confidential