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pdfEPA FORM U
2016
Primary
Page
U.S. Environmental Protection Agency
Washington, DC 20460
Partial Updating of TSCA Inventory Data Base
Site Report
Form U
(Section 8(a) Toxic Substances Control Act, 15 U.S.C. 2607(a))
2016
1
of 6 .
Check all that apply
Original 2016 submission
X
Joint submission(s)- as primary
submitter
X
Joint submission – as secondary
submitter
Revision to an original submission
CERTIFICATION
Certification Statement: I hereby certify to the best of my knowledge and belief that all information entered on this
form is complete and accurate.
I further certify that, pursuant to 15 U.S.C. § 2613(c), for all claims for protection for any confidential information
made with this submission, all information submitted to substantiate such claims is true and correct, and that it is
true and correct that the person submitting the claim has:
(i) taken reasonable measures to protect the confidentiality of the information;
(ii) determined that the information is not required to be disclosed or otherwise made available to the public
under any other Federal law;
(iii) a reasonable basis to conclude that disclosure of the information is likely to cause substantial
harm to the competitive position of the person; and
(iv) a reasonable basis to believe that the information is not readily discoverable through reverse
engineering.
Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18 U.S.C. § 1001.
Signature
Official
Title
Name (printed)
Email
Date Signed
Address
1.A.5
1.A.7
PART I. COMPANY & SITE IDENTIFICATION INFORMATION
SECTION A. PARENT COMPANY INFORMATION
Parent Company Name
Parent Company Dun & Bradstreet Number
Parent Company Address
(line 1)
Parent Company Address
(line 2)
City
1.A.6
County/Parish
State
1.A.8
Zip Code
1.B.1
1.B.2
1.B.3
1.B.4
1.B.5
1.B.7
SECTION B. SITE INFORMATION
Site Name
Site Dun & Bradstreet Number
Site Address (line 1)
Site Address (line 2)
City
1.B.6 County/Parish
State
1.B.8 Zip Code
1.A.1
1.A.2
1.A.3
1.A.4
EPA FORM U
1.C.1
1.C.2
1.C.3
1.C.4
1.C.5
1.C.6
1.C.7
1.C.10
2016
Primary
Page 2
of 6 .
SECTION C. TECHNICAL CONTACT INFORMATION
Prefix
First Name
Middle Initial
Last Name
Suffix
Company Name
Telephone
Email Address
Mailing Address (line 1)
Mailing Address (line 2)
City
1.C.8
State
1.C.9 Zip Code
Country
*Confidentiality claims for information in Part I, Sections A, B, and C, are made, as necessary, for each chemical substance on subsequent pages.
PART II. MANUFACTURING INFORMATION
2.A.1
2.A.2
2.A.4
SECTION A. CHEMICAL IDENTIFICATION
CBI for Chemical Identification
Chemical Identifying Number
2.A.3
Chemical Name
Number ID Code
2.A.5
SECTION A. JOINT SUBMISSION INFORMATION (Primary Submitter only)
Trade name
2.A.6
Other Information
2.A.7
Secondary Company
Name
Secondary Company
Address
City
2.A.7
2.A.9
2.B.1
2.B.2
2.A.10
State or
2.A.11 Zip
Province
Code
SECTION B. MANUFACTURING INFORMATION
CBI for Company Identification
2.B.10
Number of Workers
2.B.11
Maximum
CBI for Site Identification
Concentration
2.B.12
2.B.3
CBI for Technical Contact
Information
Report
Report CY 2015 Production Volume
Activity
2.B.5
2.B.6
2.B.7
2.B.8
2.B.9
CBI
2.B.13
Domestically
Manufactured
CBI
2.B.14
Imported
CBI
2.B.15
CBI
2.B.16
Other Solid
CBI
CBI
2.B.17
2.B.18
Gas or Vapor
Liquid
2.B.19
NKRA
Chemical never
physically at site
Volume used on site
Volume Exported
M or I
2.A.12
Dry Powder
Pellets or Large
Crystals
Water or Solvent
Wet Solid
X
Country
CBI
CBI
Is chemical being
recycled?
Physical Form
2.B.4
NA
CBI
a. Physical
Form
Check
all that
apply
CBI
b. % PV in
Each Physical
Form
Percent
CBI
EPA FORM U
2016
Primary
b. CY 2013
PV
CBI
a. CY 2014
PV
CBI
Report Past
PV
2.B.20
Page 3
of 6 .
c. CY 2012
PV
CBI
d.
PV
CBI
PART III. PROCESSING AND USE INFORMATION
SECTION A. INDUSTRIAL PROCESSING AND USE
c. Industrial
d. Percent
a. Type of
b. Sector(s)
Function
Production
Process or Use
Category
Volume
Code
CBI
Code
CBI
Code
CBI
%
CBI
N/A
e. Number of
Sites
Code
f. Number of
Workers
CBI
Code
CBI
3.A.1
3.A.2
3.A.3
3.A.4
3.A.5
3.A.6
3.A.7
3.A.8
3.A.9
3.A.10
SECTION B. CONSUMER AND COMMERCIAL USE
b. Consumer or
c. Used in Products
d. Percent
a. Product
Commercial
Intended for
Production
Category
or both
Children?
Volume
Code
3.B.1
3.B.2
3.B.3
3.B.4
3.B.5
3.B.6
3.B.7
3.B.8
3.B.9
3.B.10
CBI
Code
CBI
Code
CBI
%
CBI
N/A
e. Maximum
Concentration
Code
CBI
f. Number of
Commercial Workers
Reasonably Likely to
be Exposed
Code
CBI
EPA FORM U
1.C.1
1.C.2
1.C.3
1.C.4
1.C.5
1.C.6
1.C.7
1.C.10
2016
Primary
Page 4
of 6 .
SECTION C. TECHNICAL CONTACT INFORMATION
Prefix
First Name
Middle Initial
Last Name
Suffix
Company Name
Telephone
Email Address
Mailing Address (line 1)
Mailing Address (line 2)
City
1.C.8
State
1.C.9 Zip Code
Country
*Confidentiality claims for information in Part I, Sections A, B, and C, are made, as necessary, for each chemical substance on subsequent pages.
PART II. MANUFACTURING INFORMATION
2.A.1
2.A.2
2.A.4
SECTION A. CHEMICAL IDENTIFICATION
CBI for Chemical Identification
Chemical Identifying Number
2.A.3
Chemical Name
Number ID Code
2.A.5
SECTION A. JOINT SUBMISSION INFORMATION (Primary Submitter only)
Trade name
2.A.6
Other Information
2.A.7
Secondary Company
Name
Secondary Company
Address
City
2.A.7
2.A.9
2.B.1
2.B.2
2.A.10
State or
2.A.11 Zip
Province
Code
SECTION B. MANUFACTURING INFORMATION
CBI for Company Identification
2.B.10
Number of Workers
2.B.11
Maximum
CBI for Site Identification
Concentration
2.B.12
2.B.3
CBI for Technical Contact
Information
Report
Report CY 2015 Production Volume
Activity
2.B.5
2.B.6
2.B.7
2.B.8
2.B.9
CBI
2.B.13
Domestically
Manufactured
CBI
2.B.14
Imported
CBI
2.B.15
CBI
2.B.16
Other Solid
CBI
CBI
2.B.17
2.B.18
Gas or Vapor
Liquid
2.B.19
NKRA
Chemical never
physically at site
Volume used on site
Volume Exported
M or I
2.A.12
Country
CBI
CBI
Is chemical being
recycled?
Physical Form
2.B.4
NA
Dry Powder
Pellets or Large
Crystals
Water or Solvent
Wet Solid
CBI
a. Physical
Form
Check
all that
apply
CBI
b. % PV in
Each Physical
Form
Percent
CBI
EPA FORM U
2016
Primary
b. CY 2013
PV
CBI
a. CY 2014
PV
CBI
Report Past
PV
2.B.20
Page 5
c. CY 2012
PV
CBI
of 6 .
d.
PV
CBI
PART III. PROCESSING AND USE INFORMATION
SECTION A. INDUSTRIAL PROCESSING AND USE
c. Industrial
d. Percent
a. Type of
b. Sector(s)
Function
Production
Process or Use
Category
Volume
Code
CBI
Code
CBI
Code
CBI
%
CBI
N/A
e. Number of
Sites
Code
f. Number of
Workers
CBI
Code
CBI
3.A.1
3.A.2
3.A.3
3.A.4
3.A.5
3.A.6
3.A.7
3.A.8
3.A.9
3.A.10
SECTION B. CONSUMER AND COMMERCIAL USE
b. Consumer or
c. Used in Products
d. Percent
a. Product
Commercial
Intended for
Production
Category
or both
Children?
Volume
Code
3.B.1
3.B.2
3.B.3
3.B.4
3.B.5
3.B.6
3.B.7
3.B.8
3.B.9
3.B.10
CBI
Code
CBI
Code
CBI
%
CBI
N/A
e. Maximum
Concentration
Code
CBI
f. Number of
Commercial Workers
Reasonably Likely to
be Exposed
Code
CBI
Page 6
of 6 .
Paperwork Reduction Act Notice
The annual public burden for this collection of information, which is approved under OMB
Control Number 2070-0162, varies depending on the submitter’s experience with CDR
reporting, and is estimated to average 126.44 hours per year for the average multi-chemical
submission of 7.5 chemicals per site with 22% of reports consisting of partial reports and
15% of sites as new reporters. A full report includes manufacturing, processing, and use
information. A full report includes manufacturing, processing, and use information. A partial
report includes manufacturing information and does not include processing and use
information. According to the Paperwork Reduction Act, "burden" means the total time, effort,
or financial resources expended by persons to generate, maintain, retain, or disclose or
provide information to or for a Federal agency. For this collection it includes the time needed
to review instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information; processing and maintaining
information; and disclosing or providing information; adjust the existing ways to comply with
any previously applicable instructions and requirements; train personnel to be able to
respond to a collection of information; search data sources; complete and review the
collection of information; and transmit or otherwise disclose the information. An agency may
not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB number. The OMB control number for this collection
appears above. In addition, the OMB control numbers for EPA's regulations, after initial
display in the final rule, are listed in 40 CFR part 9. Expiration. XXXX .
Send comments on the Agency's need for this information, the accuracy of the provided
burden estimates, and any suggested methods for minimizing respondent burden (including
the use of automated collection techniques) to: Director, Collection Strategies Division, U.S.
Environmental Protection Agency (Mail Code 2822), 1200 Pennsylvania Ave, N.W.,
Washington, D.C. 20460. Include the OMB control number in any correspondence, but do
not submit the completed form to this address. The requested information should be
submitted in accordance with the instructions accompanying the form, or as specified in the
corresponding regulation.
EPA Form Number <7740-8> (Rev December 2015) – Previous editions are obsolete
Form Approved OMB Number 2070-0162 (Expiration XXXX)
Page: 1
EPA FORM U
2016
Joint
Page
U.S. Environmental Protection Agency
Washington, DC 20460
Partial Updating of TSCA Inventory Data Base
Site Report
Form U
(Section 8(a) Toxic Substances Control Act, 15 U.S.C. 2607(a))
2016
1
of 3 .
Check all that apply
Original
2016 submission
Joint submission – as secondary
submitter
Revision to an original submission
Part IV. Joint Submission – Secondary Submitter
4.A.1
4.A.2
4.A.3
4.A.4
4.A.6
4.A.8
PART IV. SECONDARY COMPANY IDENTIFICATION INFORMATION
SECTION A. SECONDARY COMPANY INFORMATION
Secondary Company
Name
Secondary Company
Address (line 1)
Secondary Company
Address (line 2)
City
State
Country
4.A.5
4.A.7
County/Parish
Zip Code
X
Joint submission(s)- as primary
submitter
X
Page: 2
EPA FORM U
2016
Joint
Page
4.B.1
4.B.2
4.B.3
4.B.4
4.B.5
4.B.6
4.B.7
State
4.B.10 Country
4.D.2
4.D.3
.
SECTION B. SECONDARY TECHNICAL CONTACT INFORMATION
Prefix
First Name
Middle Initial
Last Name
Suffix
Company Name
Telephone
Email Address
Mailing Address (line 1)
Mailing Address (line 2)
City
4.B.
County/Parish
4.B.8
4.D.1
of
4.B.9
Zip Code
SECTION D. TRADE PRODUCT IDENTIFICATION INFORMATION
Trade product name
a. Chemical Name
CBI
b. Chemical Identifying
Number
c. ID Code
Other Information
+Formulations provided by secondary submitters are held as confidential
d. Percent of
Formulation +
Paperwork Reduction Act Notice
The annual public burden for this collection of information, which is approved under OMB
Control Number 2070-0162, varies depending on the submitter’s experience with CDR
reporting, and is estimated to average 126.44 hours per year for the average multi-chemical
submission of 7.5 chemicals per site with 22% of reports consisting of partial reports and
15% of sites as new reporters. A full report includes manufacturing, processing, and use
information. A full report includes manufacturing, processing, and use information. A partial
report includes manufacturing information and does not include processing and use
information. According to the Paperwork Reduction Act, "burden" means the total time, effort,
or financial resources expended by persons to generate, maintain, retain, or disclose or
provide information to or for a Federal agency. For this collection it includes the time needed
to review instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information; processing and maintaining
information; and disclosing or providing information; adjust the existing ways to comply with
any previously applicable instructions and requirements; train personnel to be able to
respond to a collection of information; search data sources; complete and review the
collection of information; and transmit or otherwise disclose the information. An agency may
not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB number. The OMB control number for this collection
appears above. In addition, the OMB control numbers for EPA's regulations, after initial
display in the final rule, are listed in 40 CFR part 9. Expiration XXXX.
Send comments on the Agency's need for this information, the accuracy of the provided
burden estimates, and any suggested methods for minimizing respondent burden (including
the use of automated collection techniques) to: Director, Collection Strategies Division, U.S.
Environmental Protection Agency (Mail Code 2822), 1200 Pennsylvania Ave, N.W.,
Washington, D.C. 20460. Include the OMB control number in any correspondence, but do
not submit the completed form to this address. The requested information should be
submitted in accordance with the instructions accompanying the form, or as specified in the
corresponding regulation.
EPA Form Number <7740-8> (Rev December 2015) – Previous editions are obsolete
Form Approved OMB Number 2070-0162 (Expiration XXXX)
| File Type | application/pdf |
| File Modified | 2018-10-19 |
| File Created | 2018-10-17 |