6300.3 DCI Requirements Status

Form Approved.

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460

OMB Control Nos.
2070-0057; 2070-0107;
2070-0122; 2070-0164

REQUIREMENTS STATUS AND REGISTRANT’S RESPONSE

Paperwor k Reduction Act Notice: The public reporting bu rden for this collection of informati on is estimated to average XXXX h our per resp onse for reregi strati on and specia l review acti vities , including time for reading the
instructions and completing the necessary forms. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to: Director, Collection Strategies
Division (2822T), U.S. Environmental Protection Agency, Washington, DC 20460. Do not send the form to this address.
INSTRUCTIONS: Please type or print in ink. Please read carefully the attached instructions and supply the information requested on this form. Use additional sheets if necessary.
1. Company Name and Address

2. Case # and Name

3. Date and Type of DCI

Chemical # and Name

P

4. Guideline
Requirement
Number

5. Study Title

R

6. Use
Pattern

Progress
Reports

O
T

7. Test
Substance

8. Time
Frame

O
C

1

2

3

O
L

10. Certification
I certify that the statements made on this form and all attachments are true, accurate and complete. I acknowledge that any knowingly false or misleading statement may be
punishable by fin or imprisonment or both under applicable law.

11. Date

Signature of Company’s Authorized Representative
12. Name and Title (Please Print or Type)

EPA Form ______

13. Phone Number

9. Registrant
Response