6300.4 DCI Response

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

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

DATA CALL-IN 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

3. Date and Type of DCI

2. Case # and Name
Chemical # and Name

4. EPA Product Registration

5. I wish to cancel this
product registration
voluntarily

6. Generic Data
6a. I am claiming a Generic Data
Exemption because I obtain the
active ingredient from the source
EPA registration number listed
below.

7. Product Specific Data
6b. I agree to satisfy Generic
Data requirements as indicated
on the attached for entitled
“Requirements Status and
Registrant’s Response.”

7a. My product is an MUP and I
agree to satisfy the MUP
requirements as indicated on the
attached for entitled “Requirements
Status and Registrant’s Response.”

8. 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.

7a. My product is an EUP and I
agree to satisfy the EUP
requirements as indicated on
the attached for entitled
“Requirements Status and
Registrant’s Response.”

9. Date

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

EPA Form ______

11. Phone Number