Attachment A-11 Form 8570-37

OMB Control Nos. 2070-NEW
Expiration Date:XX/XX/XXXX

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
1200 Pe nnsylvania 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-NEW. Responses to this collection of information
are mandatory 40 CFR 158. An agency may not conduct or sponsor, a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control No.. The public reporting and
recordkeeping burden for this collection of information is estimated 0.25 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

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
Attach-2