EPA Form 7710-51 Dioxin/Furans Report

Page 1 of 6
United States Environmental Protection Agency
Washington, DC 20460
Form approved
OMB No. 2070-0054

Dioxins / Furans Report
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
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, 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

Confidential

Example 1: Process Block Flow Diagram

Production

Chlorophenols
Recycle
Phenol

Scrubber

ChloroPhenols
Recycle

HC1
Byproduct

Hydrocarbon/
Water Separator

Scrubber


Wastewater to
treatment

Chlorophenols
Recycle
Off-gas

Phenol
Chlorine
A1C1, Catalyst

Water

Reactor
65 to 180° C

Purification
Still
315 325° C
10 PSIA

Prill
Tower
150 200° C

Pentacholorphenol



Spills, floor sweepings
to landfill



Still bottoms
to incinerator

Treatment
Wastewater from 
Wastewater from
other processes

Neutralization

Clarifier

Aeration
Lagoon


Clarified


Product: Pentacholorphenol
Intermediates: None
Co-products / By-products: HCL

10% sludge
to landfill



Treated effluent to
NPDES discharge

Page 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 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)

(7) Mark (x) the destination(s)
of releases to water
EPA Form 7710-51

Confidential
(3)

Media of
release
(4)

□ POTW (Publicly owned
treatment works)

Control technology
(5)

□ Navigable
water

□ Other

(Specify)

Confidential
(6)

□ Mark (x) this

box if you attach a
continuation sheet

Page 4 of 6

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.
Past 12-month production (kg/year)

Confidential

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)
Sitelimited

Industrial

Commercial

Confidential
(8)

Consumer

□ 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

Page 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 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.

Worker Activity
(1)

Confidential
(2)

Physical
Forms
(3)

□ Mark (x) this box if you attach a continuation sheet
EPA Form 7710-51

(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.

Confidential
(4)

Maximum
Number
(5)

Confidential
(6)

Maximum Duration
Hrs/Day
(7)

Days/Yr
(8)

Confidential
(9)

Page 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 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
page numbers
(2)

Attachment name
(1)

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

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.

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 I - General Information

Part IV - List of Attachments

Section B - Chemical Identity Information

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.

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.

Optional Information

Part II - Process and Release Information

You may include with the form any information that you
want EPA to consider in evaluating the substance.

Section A - Flow Diagram

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

Section A - Submitter Identification
Person submitting notice - Enter information on the official
who signs the general Certification on page 6.

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.

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:

Category of Use
Cross-linking agent
for epoxy-type
coatings for metal
surfaces

Formulated
Product as
Manufactured

Percent of Chemical Substance

none; distributed
neat

Flame retardant for
cotton apparel

none; distributed
neat

Surfactant in
automobile spray
wax

spray auto wax
(suspension)

Colorant for paper
and other
cellulosics

colorant (solution)

N/A

N/A

4

56

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.

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.

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.

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

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.

EPA Form 7710-51