Attachment I-1: Proposed New e-CSF Form

OMB Control No. 20XX-XXXX
Approval expires XX/XX/XXXX

Environmental
Protection Agency
 Please read the instructions

Preliminary
Questions

Confidential Statement of Product
Specifications - DRAFT

 Please type or print clearly in black ink

2.
Canadian Registration
US Registration

 Leave shaded areas blank

3. PMRA Formulation # & Version #

5. Is the product a Repack?

Health
Canada

of

 This form can be saved using Adobe Acrobat

Date Received

4. EPA Basic Formulation
OR Alternate Formulation No.

Submission/File No.

YYYY-MM-DD

6. Is the product a Microbial?

8. What is the product type? Technical Grade Active Ingredient

1.
Page

7. Does the product have food uses?

Integrated Systems Product

End Use Product

Manufacturing Concentrate

General Information
9. Product Name

10. Product Regn No.

11. Name of Applicant/Registrant

Product
12. Formulation Type Code
Properties

16. Flash Point

13. Specific Gravity/Density
to
Units

17. Flame Extension

Units

14. @ Temp

Units

Units

18. Viscosity (mPa(s))

15. Weight/Formulated Piece

Units

19. pH Range

Company Code

Certification of Approving Official
“I certify that all the information contained within this form is true and complete”
20. Is this CSPS being provided on behalf of another Applicant/Registrant (3rd Party Confidential)? Yes
21. Position Title

No

22. Name

23. Signature

24. Address

25. City

26. Province/State
29. Date

27. Country
30. Phone No.

YYYY-MM-DD

XXX-XXX-XXXX

31. Fax

32. email
XXX-XXX-XXXX

Agency/Office Review
Reviewer
Screened
by

Reviewer

Date
YYYY-MM-DD

Date
Approved by

YYYY-MM-DD

28. Postal Code/ZIP

OMB Control No. 20XX-XXXX
Approval expires XX/XX/XXXX

Product Name

Product Registration No.

Date Received

Submission/File No.

YYYY-MM-DD

1.
Page

of

Components
33. Row

Names

34.

Active

Formulant/Inert

37. Common Name (ISO Proposed or Accepted)

38. Chemical Name (IUPAC or CAS name if applicable)

35. Is this a member of a set of multiple active
guarantees, or alternate formulants/inerts?
Yes
Set

Informatio
n and
Limits

39. Reg. or Sub/File No.

Label
Guarantee

47. Label Guarantee

Microbial
and Other

36. Trade Name

Impurity

40.%Purity

41. CAS#

42. Purpose in Formulation

43. % LCL

48. Value

52. Culture Collection Deposit

ACT IN

ACT OUT

53. Potency

NACT

LIST

54. Viability

49. Units

44. % Nominal

Certified Limits of Label Guarantee
(for pure active ingredient)

45. % UCL

50. LCL

46.
%w/
w

51. UCL

55. Other information

ACTIONS

PC Codes

Admin.

33. Row

Names

34.

Active

Formulant/Inert

37. Common Name (ISO Proposed or Accepted)

38. Chemical Name (IUPAC or CAS name if applicable)

35. Is this a member of a set of multiple active
guarantees, or alternate formulants/inerts?
Yes
Set

Informatio
n and
Limits

39. Reg. or Sub/File No.

Label
Guarantee

47. Label Guarantee

Microbial
and Other

36. Trade Name

Impurity

40.%Purity

41. CAS#

42. Purpose in Formulation

43. % LCL

48. Value

52. Culture Collection Deposit

ACT IN

ACT OUT

53. Potency

NACT

LIST

54. Viability

49. Units

44. % Nominal

Certified Limits of Label Guarantee
(for pure active ingredient)

45. % UCL

50. LCL

46.
%w/
w

51. UCL

55. Other information

ACTIONS

PC Codes

Admin.

33. Row

Names

34.

Active

Formulant/Inert

37. Common Name (ISO Proposed or Accepted)

38. Chemical Name (IUPAC or CAS name if applicable)

35. Is this a member of a set of multiple active
guarantees, or alternate formulants/inerts?
Yes
Set

Informatio
n and
Limits

39. Reg. or Sub/File No.

Label
Guarantee

47. Label Guarantee

Microbial
and Other

36. Trade Name

Impurity

40.%Purity

42. Purpose in Formulation

43. % LCL

48. Value

52. Culture Collection Deposit

ACT IN

41. CAS#

ACT OUT

53. Potency

NACT

LIST

54. Viability

ACTIONS

49. Units

44. % Nominal

Certified Limits of Label Guarantee
(for pure active ingredient)

45. % UCL

50. LCL

51. UCL

55. Other information

PC Codes

Admin.

56. Total weight (%)

46.
%w/
w

OMB Control No. 20XX-XXXX
Approval expires XX/XX/XXXX

Product Name

Product Registration No.

Date Received

Submission/File No.

YYYY-MM-DD

1.
Page

of

Sites & Suppliers
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

59. Name

60. Address

61. City
Company
Code

62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

59. Name

60. Address

61. City

Formulant Supplier
57.

Manufacturing Site
Formulating Site

58.
Row Number(s) of
the Component(s)

Company
Code
62. Province/State

63. Country

64. Postal Code/ZIP

Formulant Supplier
PMRA/ARLA 6003 (xx/20xx)

EPA Form 8570-4 (Rev. X-XX)