EPA Form 8570-4 Confidential Statement of Formula

Confidential Business Information: Does Not Contain National Security Information (E.O. 12065)

Form Approved. OMB. Nos. 2070-0040; 2070-0060

Instructions and Paperwork Act Notice

Please Read Carefully Before Completing This Form

Paperwork Reduction Act Notice
The public reporting burden for this collection of
information is estimated to average 1.0 hour per
response, including familiarization with the form,
organizing the necessary information, and
completing the form. Send any 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, U.S. Environmental Protection
Agency, 1200 Pennsylvania Avenue, N.W.,
Washington, D.C. 20460.
Instructions

4. Rcgistlation Number/Filc Symbol: Enter the EPA registration number or
file symbol, if known for this product
5. EPA Product Manager/Team Number: Enter the name and team
number of the EPA Product Manager assigned to this product, if known.
6. Country Where Formulated: Specify the country where this product is
formulated
7. Weight per Gallon/Bulk Density: For a liquid product specify pounds per
gallon of formulated product. For a powder or granular product, enter the bulk
density of formulated product (as used). Enter weight per unit if the product is
produced as a tablet, briquette, or other uniformly shaped product
8. pH: Enter the pH of aqueous formulations and products which are either
dispersible or soluble in water. If not applicable enter “N/A”.
9. Flash Point/Flame Extension: Specify the flash point as determined by
the regulations for pressurized products and/or products known or suspected
to burn. State the results of the flame extension test for pressurized products
including positive flashbacks.

The complete chemical composition of each pesticide must be known so it can 10. Components in Formulation: List as actually introduced into the
formulation. For each component in your formulation, provide the product
he evaluated for registration under the Federal Insecticide, Fungicide, and
name, commonly accepted chemical, the trade name, and the Chemical
Rodenticide Act, as amended.
Abstract (CAS) number for each identifiable ingredient present in the product.
CAS numbers may be obtained from the Chemical Abstract Service of the
This form is designed for reporting the ingredients used in the formulation of
a pesticide product. It must be completed and submitted with each application American Chemical Society, Columbus, OH. For each original and alternate
source of each active ingredient in the product, indicate the percent purity of
for new registration of a pesticide and application for amended registration if
the manufacturing use product, technical product, or other source of active
the revision involves a formula change.
ingredient. If one or more components will be obtained from more than one
source, enter all alternate sources and all alternate EPA Reg. Nos. in blocks
Block A: Check the appropriate action for which you are submitting the
10, 11, and 12 or on a separate attachment.
form.
Block B: Number all pages consecutively. Enter on each page the total
number of pages submitted. If more than one page is required, number them
“1 of 2”, “2 of2”, “3 of 3”, etc.
1. Name and Address of Applicant/Registrant: Enter the name and
address of your firm or authorized agent.
2. Name and Address of Producer: Specify the name of the producer and
the address of the site where this product will be produced.
3. Product Name: Specify the complete name of this pesticide product as it
will appear on the label. This name must be the same as that which appears
on the application form.

EPA Form 8570-4 (Rev. 8-94) Reverse

12. EPA Reg. No.: Specify the EPA registration number, if any, for each
active ingredient in the formulation. If an unregistered active ingredient is
used, have the suppliers submit the chemical specifications, as well as any
data required under 40 CFR Part 158.
13. Each Component in Formulation
a. Amount: Specify the quantity of each component as actually
introduced into the formulation. Units (e.g., pounds, grams, gallons, liters)
should be expressed as used in the formulation. If the quantity is a liquid
measure, enter the volume and the specific gravity or the pounds per
gallon of the component.
b. Percent by Weight: Specify the weight percentage of each component
in your formulation. Check Your Calculations. Note that the weight
percentage in many cases will not agree with that shown on the label
ingredient statement where the weight percentage of the per active
ingredient(s) must he declared.
Attention: Producers of Microbial Products: Special Instructions for
Column 13b.) Please state the percent of active ingredient in British
International Units (BIUs), International Toxic Units (ITUs),
Polyhedral Inclusion Bodies (PIBs)(viruses), Colony Forming Units
(CFUs)(Fungi), as appropriate, and include an equivalent statement of
active ingredient per milligram, ounce, pound, etc. of product (e.g., a 50%
active Bacillus thuringiensis product may have an equivalency value of
1.59 million Aedis aegypti ITU per pound of product).
14. Certified Limits: These limits are to be set based on representative
sampling and chemical analysis (i.e., quality control) of the product.
a. Upper Limit: Specify the maximum percentage of each active
ingredient, intentionally added inert ingredient, and any impurities greater
than 0.1% to he permitted in the product.

Attention: (Special Instructions for Columns 10, 13, and 14) Any
impurities greater than or equal to 0.1% (or less than 0.1% if the impurity is
toxicologically significant) which are associated with the active ingredient(s)
of n technical grade (manufacturing or reformulating use) product or an end
use product produced by an integrated formulations system should also be
listed in column 10, and the corresponding amount, percent by weight, and
upper certified limits in columns I3 and 14.

b. Lower Limit: Specify the minimum percentage of each active
ingredient and intentionally added inert ingredient to he permitted in the
product.

11. Supplier Name and Address: Provide the name and address of the
supplier of each component in the formulation. If one or more components
will be obtained from more than one source, specify the names addresses of
the alternate sources also.

16. Typed Name of Approving Official: Complete this item for
identification of individual to he contacted if necessary

15. Purpose In Formulation: Specify the purpose of each ingredient both
active and inert. (For example, disinfectant, herbicide, synergist
surfactant, defoamer, sequestrant, etc.) If space is insufficient, abbreviate.

17. Total Weight: Specify the total weight of the batch (column 13a.)
18-21: Complete these items for identification of individual to be
contacted if necessary.

*U.S. GOP: 2000-519-239/94558