Form 6300-4

Page 1

United States Environmental Protection Agency
Washington, D.C. 20460
DATA CALL-IN RESPONSE

of

1

OMB Approval 2070-0174
Expiration Date: 12/31/2025

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. 2070-0174. 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
and record keeping burden for this collection of information is estimated to 20 to 8128 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 Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this address.
INSTRUCTIONS: Please type or print in ink. Please read carefully the attached instructions and supply the information requested on this form. Use
additional sheet(s) if necessary.
1. Company Name and Address

3. Date and Type of DCI and Number

2. Case # and Name

[Company Name]

[Case #] [Chemical Name]

[Company Address]

4. EPA Product
Registration

5. I wish to cancel
this product
registration
voluntarily

6. Generic Data
6a. I am claiming a Generic Data
Exemption because I obtain the
active ingredient from the source
EPA registration number listed
below.

[Date email sent]
GENERIC
ID # GDCI-[GDCI #]
7. Product Specific Data

6b. I agree to satisfy Generic Data
Requirements as indicated on the
attached form entitled
"Requirements Status and
Registrant's Response."

7a. My product is an MUP and I
agree to satisfy the MUP
requirement on the attached form
entitled "Requirements Status and
Registrant's Response."

[List reg no for all active
products under this
registrant]

N/A

N/A

8. Certification: I certify that the statements made on this form and all attachments are true, accurate, and complete. I acknowledge that any knowingly
false or misleading statement may be punishable by fine, imprisonment or both under applicable law.
Signature and Title of Company's Authorized Representative
Initial to indicate certification as to information on this page
(full
of certification
10. text
Name
of Companyis on page one).
EPA FORM 6300-4

7b. My product is an EUP and I
agree to satisfy the EUP
requirement on the attached form
entitled "Requirements Status and
Registrant's Response."

9. Date
Date
11. Phone Number