9600-015 Secondary Notify Tertiary

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

EPA CDR
U.S. Environmental Protection Agency
Secondary Form U
Washington, DC 20460

Chemical Data Reporting
Site Report
(Section 8(a) Toxic Substances Control
Act, 15 U.S.C. 2607(a))

Submission Date:

Included in this submission:
Original submission
Revised submission
Secondary or Tertiary submission
X

Notifying a Tertiary submitter

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

CBI

Name of Authorized Official
Company Name

Position

Email Address

Phone Number

Mailing Address 1

Mailing Address 2

City

State

Postal Code

Part I. SECONDARY COMPANY INFORMATION
Secondary Company Name
Secondary Company Address 2
Secondary Company
County/Parish
Secondary Company Zip/Postal
Code

Form #: 9600-015

Secondary Company
Address
Secondary Company
City
Secondary Company
State/Province/Other
Secondary Company
Country

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

Part II. TRADE PRODUCT INFORMATION
Section A. Trade Product Information

CBI

Trade Product Name or Provided
Company Trade Name

Section A.1 Chemical Substance Identification
Tertiary Product Information
Trade Product Name or Other
Designation

Other Information

Tertiary Company Name

Tertiary Company Email Address

Tertiary Company Address

Tertiary Company Address 2

City/Town

State/Province/Other

Zip Code

Country

Unique Identifier

Section A.2 Primary Company Information

CBI

Parent Company

Plant Site

Plant Site Mailing Address

Is the relationship confidential?

Section B. Technical Contact Information

CBI

Technical Contact Information is confidential?
Contact Name

Company Name

Phone Number
Mailing Address 1

Email Address
Mailing Address 2

City

State

Postal/Zip Code

Country

Form #: 9600-015

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

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.
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:

Form #: 9600-015

Yes

No

CBI

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

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.

Form #: 9600-015

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

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 #: 9600-015

OMB Control #: 2070-0162

Expiration Date: 6/30/2023

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 #: 9600-015