EPA Form 8570-37 Self-Certification Statement for the Physical/Chemical P

Form Approved. OMB Nos. 2070-0060; 2070-0174

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
120 0 Pe nn sylv ania Avenue, N.W .
WASHING TON , D.C. 20460
Paperwork Reduction Act Notice: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
2070-0060). Responses to this collection of information are mandatory (40 CFR 158). 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 control number. The public reporting burden for this collection of information is estimated to
average 0.25 hours per response. 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Avenue, N.W.,
Washington, DC 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

SELF-CERTIFICATION STATEMENT FOR THE
PHYSICAL/CHEMICAL PROPERTIES (PR NOTICE 98-1)
Product Name:
Reg. No./File Symbol No.
(if known) or Company No.

SELF-CERTIFICATION STATEMENT:
I certify that the reported information on the “Summary Form” represents a true and accurate record of
the test results of studies generated or owned by (Company Name):
and that the values of the properties reported are reliable.
I further certify that such data were generated in substantial conformity with OPPTS Test Guideline Series 830
Product Properties, applicable to my product, and in effect at the time of submission.
As a condition of registration, EPA may, by order, (1) withdraw a pending registration, (2) suspend the
registration of this product without opportunity for hearing, or (3) assess civil penalties provided for in section
14 of FIFRA for violations of section 12(a)(2)(N) of FIFRA without opportunity for hearing, if I have not
submitted to EPA within thirty (30) days of receipt of a request by the Agency, or within a specified time
agreed to by the Agency, test results of studies summarized in the “Summary Form.”
As a condition of registration, EPA may, by order, (1) withdraw a pending registration, (2) suspend the
registration of this product without opportunity for hearing, or (3) assess civil penalties provided for in section
14 of FIFRA for violations of sections 12(a)(2)(N), 12(a)(2)(Q), or 12(a)(2)(R) of FIFRA without opportunity
for hearing, if I fail to provide to EPA within thirty (30) days of receipt of a notification of error, or within
a specified time agreed to by the Agency, information that EPA determines is required to correct the error.
Type Applicant’s Name:
Title:

Telephone No.

Applicant’s Signature:

Date:

EPA Form 8570-37 (12-2003)

Attach-2