9600-008 Notification of TSCA Fee Action

OMB Control No. 2070-0208
Expiration 2/28/2025

EPA

U.S. Environmental Protection Agency
NOTICE OF TSCA FEE ACTION PARTICIPATION

Submission Date:
Revised Date:

Part I – Submitter Identification
Name of Authorized Official
Manufacturer,
Importer, (in U.S.)

Technical Contact
(in U.S.)

(first)

Mailing Address (street, city, zip code)

CBI*

(last)

(first)

Company Name

Mailing Address (street, city, zip code)

Name

Telephone Number

(last)

* CBI refers to the term “Confidential Business Information.” Mark (X) in the CBI box(es) if the submitter information is to be held confidential.

Part II –Fee Action
TSCA Section 4 Test Rule
TSCA Section 6 Risk Evaluation
Part III – Participation Notification
I represent a company that is included on the preliminary list of manufacturers for the TSCA fee action specified in Part II. I
understand the fee obligation for this TSCA action.
I represent a company that is included on the preliminary list of manufacturers for the TSCA fee action specified in Part II. I am
requesting to be removed from the preliminary list.
I am no longer manufacturing (including importing) the chemical substance subject to the TSCA fee action specified in Part
II. In the case of an EPA-initiated risk evaluation, I ceased manufacture prior to the beginning of EPA’s prioritization process
for the subject chemical, AND
I will not be manufacturing (including importing) the chemical substance in the next 5 years from the date of this certification.
I represent a company that is included on the preliminary list of manufacturers for the TSCA action specified in Part II. I am
requesting to be removed from the preliminary list.
I have not ever manufactured (including imported) the chemical substance subject to the TSCA action specified in Part II in
the preceding five-year period.
I represent a company that is not included on the preliminary list of manufacturers for the proposed TSCA action specified in Part
II. I am requesting to be added to the preliminary list. I have manufactured (or imported) the chemical substance subject to the
TSCA fee action in the preceding five-year period.
I represent a small business concern as defined in 40 CFR 700.43, and therefore may be entitled to a reduced fee.

Part IV – Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision and the information contained
therein, to the best of my knowledge, is true, accurate, and complete. I also certify that I have manufactured, imported, or processed the above
chemical substance between the dates of June 21, 2006 and June 21, 2016. I am aware it is unlawful to knowingly submit incomplete, false and/or
misleading information, and there are significant criminal penalties for such unlawful conduct, including the possibility of fine and imprisonment.
Signature of authorized official:

Date:

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. 2070-0208).
Responses to this collection of information are mandatory (40 CFR 700.45). 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 average 0.38 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, including through the use of automated collection
techniques to the Director, Information Engagement Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed EPA Form to this address.

EPA Form 9600-008 (09/27/2018)