0586.14 Attachement D

_{IMPORTANT: Before completing this form, please read the}

accompanying instructions carefully. _{Page 1 of 6}

United States Environmental Protection Agency Washington, DC 20460

EPA

Dioxins/Furans Report

,Form Approved

0MB No. 2070-0054

When completed, send this form to:

Document Control Office (7407) Information Management Division

Office of Pollution Prevention and Toxics Environmental Protection Agency

1200 Pennsylvania Ave., NW Washington, DC 20460

For Agency Use Only

Document Control Number Docket Number

Part I - General Information

Section A - Su_-b_-m_-itt_-er_-Identification Confi-

Mark (X) the "Confidential" box next to a subsection you claim as confidential.

dential

1a. Person Name of authorized official Submitting

Title

Notice 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 a 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 a 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 I attached.)

(1 I Include intermediates, coproducts 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 IJ

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

EPA Form 7710-51 (12/2019)

EXAMPLE I - PROCESS BLOCK FLOW DIAGRAM

PRODUCTION

I

j

CHLOROPHENOLS RECYCLE

SCRUBBER

PHENOL

WATER_--

SCRUBBER

-

HYDROCARBON/ WATER SEPARATOR

© _--

_-+ HCl

_. ^BY·

PRODUCT

WASTEWATER T 0 TREATMENT

CHLOROPHENOLS RECYCLE

PHENOL

-

,. ,

CHLO RO· PHENOLS RECYCLE

REACTOR 65 TO 1800 C

-

OFF-GAS

-

PURIFI- CATION

PRILL

CHLORINE

AlCl, CATALYST

_---

• STILL

315 - 3250 C

10 PSIA

0

.

STILL BOTTOMS

TOWER

150 -

200° C

_-^-_- PENTACHLOROPH

SPILLS, FLOOR SWEEPINGS_-

,. _-

_@ ^{TO LANDFIL} L

Tl) INCINERATOR

TREATMENT

WASTEWATER FROM

WASTEWATER FROM

. OTHER PROCESSES

NEUTRAL!· ZATION

CLARIFIER

0

AERATION ' LAGOON

_CLARIFIED TREATED EFFLUENT TO NPDES DISCHARGE

PRODUCT: PENTACHLOROPHENOL INTERMEDIATES: NONE

CO-PRODUCTS/BY-PRODUCTS: HCL

lO't SLUDGE TO LANDFILL

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) the confidential box next to each item you claim as confidential. .(1) - Enter the number of each release point identified in the process description, port II, Section A.· - Estimate the amount of the chemical substance released directly to the environment or onto control technology (in kg/ day.or kg/batch). - Mark (x) this column if entries in columns (1) and/or (2) are confidential · ·· - Identify the media (air. land. or water) to which the substance will be released from the release point. (51 - Describe 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 (51are confidential (71 - Identify the destination(s) of releases to water.
Release Number (I)	Amount of substance released 12)	Confi• dential /3)	Media of release /4)	Control technology /5)				Confi- dential (6)
				□I"
(71Mark (x) the destination(s) of releases to water		D 11ea1mem worAsJ POTW (publicly owned		D waterway Navtgable	D (sv,,cd,J 01he1	·,,	Mark (x) in this box if you attach a continuation sheet

EPA Form 7710-51

Page 4 of 6

Part Ill - Production, Import, and Use Information
Mark (xi 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 minimum production volume for any consecutive 12-month period during the past 3 years of production.											Confi-· dential
Past 12-month production (kg/year)				Maximum 12-month production (kg/year)
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 conf1dential. - Describe each category of use of the chemical substance by function and application. - Mark (x) this column if entry in column (1) is confidential. - Estimate the percent of total production for the past 3 years devoted to each category of use. - 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 Manual for examples.
Category of use (1)	Confi- dential (2)	Production (percent) (3)	Confi- dential (4)		Formulation (percent) (5)	Confi- dential (6)	Mark (xJ appropriate column(s) (7/				Confi- dential (BJ
							Site- limited	Indus- trial	Com- mercial	Con- sumer
D 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 which will be provided to any person regarding protective equipment or practices for the safe handling, transport, use, or disposal of the new chemical substance. List In part IV any hazard information you include. □ Mark (x) this box if vou attach hazard information.

EPA Form 7710-51

Page 5 of 6

4. Occupational Exposure. - You must make separate confiden1ial11v claims- for the description of worker. ac1,v,1y, physical. form. of the substances, number of workers exposed, and dura1,on of ac1iv11y. Mark (x) the "Confidential" box next 10 any item you claim as confidential. (1)- Describe the activities in which workers may be exposed lo (5) - Estimate the maximum number of workers involved in the chemical substance. Include activities in which each activity. workers wear protective equipment (6).- Mark (x) this column if entry in column (5) is confidential (2)- Mark (x) this column if. entry in column (1) is confidential. (7) and (8) - Estimate the maximum duration of the activity for (3)- Indicate the physical form(s) of the chemical substance at any worker in hours per day and days per year. the time of exposure . (9) - Mark (x) this column if entries in column (7) and/or (8) are (4)- Mark (x) this column if entry in column (3) is confidential confidential
Worker Activity (1)	Confi-dential (2)	Physical Forms (3)	Confi- dential (4)	·Maximum number (5)	Confi- dential (6)	Maximum duration		Confi- dential (9)
						Hrs/day (7)	Days/yr (8)
0 Mark (x) this box if you attach a continuation sheet.

EPA Form 7710-51

Page 6 of 6

Part IV - List of Attachments
Attach continuation sheets of sections of the form and optional information alter 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 I•) the ··confidential box next to any attachment name you claim as confidential. Read the Instructions Manual for guidance on how to claim any information in an attachment as confidential. .
Attachment name (1)	Attachment page numbers (2}	Confi- dential (3}
D Mark (xi this box if you attach a continuation sheet. Enter the attachment name and numb r.
Certification i certify that to the best of my knowledge and belief: The company named in part I, section A, subsection 1a of this form manufactures. imports, or processes, other than in small quantities for research purposes, the substance identified in part I, section B. All information provided in this notice is complete and truthful as of the date of submission.
Signature of authorized official	Date	Confi- dential
Signature of agent (if applicable}	Date	Confi- dential

EPA Form 7710-51

General: Instructions

EPA Form 7710-51, Dioxins/Furans Report

You must provide all information requested in this form to the extent that it is known to or reasonably ascertainable by you. · ·· ...•

Part I - General Information

You must provide the chemical identity of the chemical substance 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 manufacture operations that you will describe in the form. You should reproduce these sec­ tions as needed.

Part Ill - Production, Import. and Use Information

You must provide production volume, percent of produc­ tion 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 IV - List of Attachments

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.

Optional Information

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

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.

1. General Instructions

Complete the form using a typewriter or by printing legi­ bly in black ink. All information must be in English. Pro­ vide 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) ot TSCA which relates solely to exposure to humans or the environment outside the Uni­ ted States.

Any manufacturer or importer using this form may photocopy the form, sections of the form, or these instructions as frequently as needed.

2. Certification

•• • > •

The official-named in Part l, 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.

3. Asserting Confidentiality Claims

A manufacturer or importer may assert a claim of confi­ dentiality for any information submitted to EPA on this form. To assert confidentiality of 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.

Part I - General Information

Section A - Submitter Identification

Person submitting notice - Enter information on the official who signed the general certification on page 6.

Section B Chemical Identity Information

Chemical Name and CAS Registry Number - list the common name and Chemical Abstracts Registry number, if available, for the chemical on which you are reporting:

II. Process and Release Information Section A - Flow Diagram

Flow diagram - Submit a block flow diagram for each major unit operation and treatment process involved in manufacturing the chemical on which you are reporting. lnclude the following information:

(l) identify the product process and chemical interme­ diates, coproducts and byproducts produced. by the process;

2. provide a block for each major unit operation (e.g.., reactor, washer, filtration, air emission control, aera­ tion lagoon, etc.) in the production process and· in the residuals management process;

3. identify aII process input such as raw materials, reagents, solvents, etc., 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 pressure is not atmospheric;

(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.

EPA Form 7710-51

Section B - Environmental Release and Disposal

Column (1)- For each release point indicated in the flow diagram (part II, 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 car­ bon filter, scrubber, and biological treatment (primary,

. secondary, etc.). Give as complete a description as possi­ ble. 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.

Part Ill - Production, Import, and Use Information

1. Production Information

Production volume - Report the production volume for the past 12 months of production. Also report the maxi­ mum production volume for any consecutive 12-month period 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.

2. Use Information

Column (1)- Identify each possible category of use of the chemical substance by describing its function and appli­ cation. "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:

⁰ a disperse dye carrier for finishing polyester fibers

⁰ a cross-linking agent for epoxy-like coatings for metal surfaces

⁰ a flame retardant for surface application 01'.l cotton apparel, textile home furnishings, and exterior canvas products .

⁰ a surfactant in automobile spray wax

⁰ 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.

Column (5)- Estimate the weight percent of the chemi­ cal substance contained in any formulated mixture, sus­ pension, emulsion, solution, or gel associated with each category of use as manufactured for commercial pur­ poses at sites under your control. Where the substance is distributed from your site neati enter N/ A for not

. applicable.

• For example:

Formulated Pro-

duct as Percent of Chem- Category of Use Manufactured ical Substance

Cross-linking agent none; distributed N/A

for epoxy-type neat coatings for metal

surfaces

Flame retardant for none; distributed N/A

cot on apparel neat

Surfactant in spray auto wax 4

automobile (suspension) spray wax

Colorant for paper colorant (solution) 55

and other cellulosics

Column (7)- Mark (x) to indicate if the category of use is site-limited. 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 manu­ facturers.

Site-limited: The substance is used only on the contig­ uous property unit where it is manufactured and not intentionally distributed outside that site except for waste disposal. This includes all factories, storage space, and warehouses at the site. An example would be an inter­ mediate which is further reacted on-site to produce a chemical product.

lndustrial:The chemical substance or products containing the substance are used only at the site of other manufac­ turers or processors, e.g., textile dyeing, paint formula­ tion, use of a resin to manufacture an article.

Commercial: The chemical substance or products con­ taining the substance are used by a commercial enter­ prise providing a consumer service, e.g.; use by commer­ cial dry cleaning establishments, use by painting contractors, or use by roofers in commercial building

. construction.

Consumer: The chemical substance or products contain­ ing 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). (BJ - 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 of the chemical. If you wish to provide any additional informa­ tion which would assist in this analysis, it may be submit­ ted as optional information.

EPA Form 7710-51

3. Hazard lnformation

Include with the form a copy or reasonable facsimile of any hazard warning statement. label, material safety data sheet, or other information which is provided to any per­ son regarding protective equipment or practices for the safe transport, use or disposal of. the chemical. Identify any copies of hazarc,1. information or warnings that you attach in Part IV, List of Attachments.

4. Occupational Exposure Information · •

Column (1 )- Describe each specific activity in the opera­ tion during which workers may be exposed to the chemi­ cal. Such activities may include charging reactor vessels, sampling for quality control, transferring materials from one work area to another, drumming, bulk loading, chang­ ing filters, and cleaning equipment. Activities must be described even if workers wear protective equipment or clothing. (Recommended protective 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, fume), even if workers wear pro­ tective 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 (BJ- Enter the maximum duration that any one worker will engage in the activity in days/year, based on the reported maximum 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 chemic.al, 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.

Paperwork Reduction Action Notice: The public reporting and record keeping burden for this collection is estimated to average about 30 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This is a mandatory collection pursuant to 40 CFR 766. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB Control Number. The OMB Control Numbers for this collection of information is OMB 2070-0054. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Director, Collection Strategies Division (Mail Code 2822T), U.S. Environmental Protection Agency, Washington, DC 20460. Include the 0MB control number in any correspondence, but do not submit the form or report to this address. The form should be submitted in accordance with the instructions on the top of the form.

Form 7710-51