ICR Attachment G - Form 7710-25

Public reporting burden for this collection of information is estimated to average 105.5 hours per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Director, Collection Strategies Division (2822), U.S. Environmental Protection Agency, 1200 Pennsylvania Ave., N.W.,
Washington, D.C. 20460; and to the Office of Management and Budget, Paperwork Reduction Act (2070-0012), Washington, D.C. 20503.

CERTIFICATION -- A Printed copy of this signature page, with original signature, must be submitted
I certify that to the best of my knowledge and belief:
1.

The company named in Part I, section A, subsection 1a of this notice form intends to manufacture or import for a
commercial purpose, other than in small quantities solely for research and development, the substance identified in Part I,
Section B.

2.

All information provided in this notice is complete and truthful as of the date of submission.

3.

I am submitting with this notice all test data in my possession or control and a description of all other data known to or
reasonably ascertainable by me as required by §720.50 of the Premanufacture Notification Rule.

Additional Certification Statements:
If you are submitting a PMN, Intermediate PMN, Consolidated PMN, or SNUN, check the following user fee certification
statement that applies:
The Company named in Part I, Section A has remitted the fee of $2500 specified in 40 CFR 700.45(b), or
The Company named in Part I, Section A has remitted the fee of $1000 for an Intermediate PMN (defined @ 40 CFR
700.43) in accordance with 40 CFR 700.45(b), or
The Company named in Part I Section A is a small business concern under 40 CFR 700.43 and has remitted a fee of $100
in accordance with 40 CFR 700.45(b).
If you are submitting a low volume exemption (LVE) application in accordance with 40 CFR 723.50(c)(1) or a Low release
and low exposure exemption (LoRex) application in accordance with 40 CFR 723.50(c)(2), check the following certification
statements:
The manufacturer submitting this notice intends to manufacture or import the new chemical substance for commercial
purposes, other than in small quantities solely for research and development, under the terms of 40 CFR 723.50.
The manufacturer is familiar with the terms of this section and will comply with those terms; and
The new chemical substance for which the notice is submitted meets all applicable exemption conditions.
If this application is for an LVE in accordance with 40 CFR 723.50(c)(1), the manufacturer intends to commence
manufacture of the exempted substance for commercial purposes within 1 year of the date of the expiration of the 30 day
review period.
The accuracy of the statements you make in this notice should reflect your best prediction of the anticipated facts regarding the chemical substance
described herein. Any knowing and willful misinterpretation is subject to criminal penalty pursuant to 18 USC 1001.
Signature and title of Authorized Official (Original Signature Required)
Date

Signature of agent - (if applicable)

Date

Do you want these signatures to be digital?

EPA FORM 7710-25 (Rev. 5-95)

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Confidential