9600-012 Form U Co-Manufacturer

OMB Control #: 2070-0162

EPA CDR
Primary Form U

FormU 2020

Expiration Date: 6/30/2023

U.S. Environmental Protection Agency
Washington, DC 20460
Chemical Data Reporting
Site Report
(Section 8(a) Toxic Substances Control
Act, 15 U.S.C. 2607(a))

Included in this submission:
Original submission
Revised submission
Manufacturer
Joint submission(s) - as primary
submitter
Co-Manufacturer submission(s) - as
contracting

X

Co-Manufacturer submission(s) - as
producing
Submission Date:

Revised Date:

CDR Certification
I certify, under penalty of law, that this document was prepared under my direction of supervision in accordance with a system designed to assure
that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the
system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief,
true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and
imprisonment for knowing violations.

TSCA CBI Certification
I certify that all claims for confidentiality asserted with this submission are true and correct, and all information submitted herein to substantiate
such claims is true and correct. Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18 U.S.C. 1001.
I further certify that:
i. I have taken reasonable measures to protect the confidentiality of theinformation;
ii. I have determined that the information is not required to be disclosed or otherwise made available to the public under any other Federal law;
iii. I have a reasonable basis to conclude that disclosure of the information is likely to cause substantial harm to the competitive position of my
company; and
iv. I have a reasonable basis to believe that the information is not readily discoverable through reverse engineering.
Signature of Authorized
Official

Name (printed)

Date Signed

Email Address

Submitting Official Information
Name of Authorized Official

CBI:

Company Name

Position

Email Address

Phone Number

Mailing Address 1
Mailing Address 2
City

State

Postal Code

Country

Form #: 9600-012

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

Part I. COMPANY & SITE IDENTIFICATION INFORMATION
Section A.1 Domestic Parent Company Information
Company Name

Company Type

Domestic Parent Company

Dun & Bradstreet Number
Mailing Address 1
Mailing Address 2

City

State

County/Parish

Postal Code

Country

US

Company Type

Foreign Company

Section A.2 Foreign Company Information
Foreign Company Name
Foreign Company Dun &
Bradstreet Number
Foreign Company Address
Foreign Company Address 2

Foreign City

Foreign State/Province/Other

Foreign County/Parish

Foreign Postal Code

~

Foreign Country

Section B. Site Information
EPA Registry ID

Program ID

Site Name

Dun & Bradstreet Number

Site Address
Site Address 2

City

State

County/Parish

Postal Code

Country

North American Industry Classification System (NAICS) Code(s)
NAICS Code

Activity Classification

111120 Oilseed (Except Soybean) Farming

Import

111333 Strawberry Farming

Manufacture

111130 Dry Pea And Bean Farming

Both

Form #: 9600-012

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

Part II. CHEMICAL SUBSTANCE INFORMATION
Section A. Chemical Substance Identification
Chemical Name

Chemical Identifying
Number
Chemical Alias

Number ID Code
Section A.1 Confidential Business Information related to this chemical Identity
Company Information Confidential:

Site Information Confidential:

Technical Contact Information Confidential:

When Chemical Identifying Number is ACCNO one of the following statements displays:
•
I wish to maintain an existing claim for the confidentiality of the chemical substance identity, as listed on the confidential portion of the TSCA
Inventory.
•
I do not wish to maintain an existing claim for the confidentiality of the chemical substance identity, as listed on the confidential portion of the
TSCA Inventory.

Section B. Technical Contact Information
Contact Name

Company Name

Phone Number

Email Address

Mailing Address 1

Mailing Address 2

City

State

Postal Code

Country

Section C. Manufacturing Information
Non-Principal Reporting Year(s) Production Volume Information

CBI

Calendar Year 2018
Calendar Year 2017
Calendar Year 2016
Section C.2 Co-manufacturer: Contracting Company
Report CY 2019 Production Volume and Co-manufacturer
Information

CBI

CBI

Check if you wish to report the joint relationship as confidential:
Chemical Name/Alias
CY2019 Contracted Production
Volume

Volume Contracted Never Physically At
Site

Producing Company Name

Producing Company Email

Producing Company Address

Producing Company Address 2

Producing Company City/Town

Producing Company
State/Province/Other
Producing Company Country

Producing Company Zip Code

Form #: 9600-012

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

Section D. Processing and Use Information
Section D.1 Industrial Processing and Use
Process and Use Information

CBI

CBI

Type of Process or Use

Sector(s)

Function Category

Percent Production Volume

Number of Sites

Number of Workers

Section D.2 Consumer and Commercial Use
Product Category Information

CBI

CBI

Product Category

Function Category

Consumer or Commercial

Used in Products Intended for Children

Percent Production Volume

Maximum Concentration

Number of Commercial Workers
Reasonably Likely to be Exposed

Part III. CONFIDENTIAL BUSINESS INFORMATION SUBSTANTIATION
A person may assert a claim of confidentiality for the specific chemical identity of a chemical substance as described in § 711.15(b)(3) of this part only
if the identity of that chemical substance is treated as confidential in the Master Inventory File as of the time the report is submitted for that chemical
substance. Generic chemical identities and accession numbers may not be claimed as confidential. To assert a claim of confidentiality for the identity
of a reportable chemical substance, you must submit with the report detailed written answers to the questions from subsection (b) and to the following
questions.
Yes
No
CBI
Substantiation Questions applicable to Chemical Identity
1. Is this chemical substance publicly known (including by your competitors) to be in U.S. commerce? If yes,
please explain why the specific chemical identity should still be afforded confidential status (e.g., the chemical is
publicly known only as being distributed in commerce for research and development purposes). If no, please
complete the certification statement: I certify that on the date referenced, I searched the internet for the chemical
substance identity (i.e., by both chemical substance name and CASRN). I did not find a reference to this chemical
substance which would indicate the chemical is being manufactured or imported by anyone for a commercial
purpose in the United States.
Explanation:
Date:
2. Does this particular chemical substance leave the site of manufacture (including import) in any form, e.g., as a
product, effluent, emission? If yes, please explain what measures have been taken to guard against the discovery
of its identity.
Explanation:
3. If the chemical substance leaves the site in a form that is available to the public or your competitors, can the
chemical identity be readily discovered by analysis of the substance (e.g., product, effluent, emission), in light of
existing technologies and any costs, difficulties, or limitations associated with such technologies? Please
explain why or why not.
Explanation:
4. Would disclosure of the specific chemical name release confidential process information? If yes, please
explain.
Explanation:

Substantiation Questions applicable to all Confidential Business Information
1. Will disclosure of the information claimed as confidential likely cause substantial harm to your business’s
competitive position? If you answered yes, describe the substantial harmful effects that would likely result to
your competitive position if the information is disclosed, including how a competitor could use such information
and the causal relationship between the disclosure and the harmful effects.

Form #: 9600-012

Yes

No

CBI

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

Explanation:
2. To the extent your business has disclosed the information to others (both internally and externally), has your
business taken precautions to protect the confidentiality of the disclosed information? If yes, please explain and
identify the specific measures or internal controls your business has taken to protect the information claimed as
confidential.
Explanation:
3.A. Is any of the information claimed as confidential required to be publicly disclosed under any other Federal
law? If yes, please explain.
Explanation:
3.B. Does any of the information claimed as confidential otherwise appear in any public documents, including
(but not limited to) safety data sheets, advertising or promotional material, professional or trade publications,
state, local, or Federal agency files, or any other media or publications available to the general public? If yes,
please explain why the information should be treated as confidential.
Explanation:
3.C. Does any of the information claimed as confidential appear in a patent or patent application? If yes, please
provide the associated patent number and explain why the information should be treated as confidential.
Explanation:
4. Does any of the information you are claiming as confidential constitute a trade secret? If yes, please explain
how the information you are claiming as confidential constitutes a trade secret.
Explanation:
5. Is the claim of confidentiality intended to last less than 10 years (see TSCA section 14(e)(1)(B))? If yes, please
indicate the number of years (between 1–10 years) or the specific date after which the claim is withdrawn.
Explanation:
6. Has EPA, another federal agency, or court made any confidentiality determination regarding information
associated with this chemical substance? If yes, please provide the circumstances associated with the prior
determination, whether the information was found to be entitled to confidential treatment, the entity that made the
decision, and the date of the determination.
Explanation:

Form #: 9600-012

OMB Control #: 2070-0162

Expiration Date: MM/DD/YYYY

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. 2070-0162).
Responses to this collection of information are mandatory (40 CFR 711). 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 recordkeeping burden for
this collection of information is estimated to be 131.5 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.”

Form #: 9600-012