ICR Attachment 9 - Screenshots from ePMN Software (including populated forms)

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PMN SUPplJtt Document
Notice of Commencement
Biotech

TERA} TIER I

Screen Shots of the PMN Form
PMN Fonn - Instruction page

When completed send this form to

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DOCUMENT CONTROL OFFICER
OFFICE OF POLLUTION PREVENTION AND TOXIC SUBSTANCES) 7407
U.s. EPA 1200 Pennsylvania, NW
WASHINGTON) DC 20460
General Instructions

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• You must provide all information requested in this form to the extent that it is known to or reasonably
ascertainable by you. Make reasonable estimates if you do not have actual data.
• Before you complete this form) you should read the 'nstructions Manual for Premanufacture Notification"
tructions Manual is available from the Toxic Substances Control Act (TSCA) Information Service by
2-554-1404, or faxing 202-554-5603).
• If a user fee has been remitted for this notice (40 CFR 700.45») indicate in the "TS" field the TS-user fee
ication number you have generated. Remember) your user fee ID number must also appear on your
ponding fee remittance, which is sent to EPA, Washington Financial Management Center (3303), P.O.
36039
tsburgh, PA 15251-6399) Attn. TSCA User fee.
• All fields are mandatory except for those denoted with < >
• If a field value is not known, enter 'NRO' for 'Not Readily Obtainable'
Part I -- GENERAL INFORMATIO
You must provide the currently correct Chemical Abs
Name of the new chemical substance, even if
you claim the identity as confidential. You may authori2
r person to submit chemical identity information
for you) but your submission will not be complete and th
not begin until EPA receives this
information. A letter in support of your submission shoul
renee your TS user fee identifica
er. You
must submit an original and two copies of this notice including all test data. If you claimed any in ormadon as
confidential, a single saniti2ed copy must also be submitted.
Part II -- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE

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If there are several manufacture) processing) or use operations to be described in Part II, sections A and B of
this notice) reproduce the sections as needed.
Part III -- LIST OF ATTACHMENTS

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Attach additional eets if there is not enough space to answer a question fully. Label each continuation sheet
with the corresponding section heading. In Part III) list these attachments, any test data or other data and any
optional information included in the notice.
OPTIONAL INFORMATION
You may include any information that you want EPA
evaluating the new substance. On page 11 of
this form, space has been provided for you to desc
revention and recycling information you may
have regarding the new substance. So-called "bindingnboxes are included throughout this form for you to
indicate your willingness to be bound to certain statements you make in this section, such as use) production
volume, protective eqUipment • . . This option is intended to reduce delays that routinely accompany the
development of consent or
Significant New Use Rules. Ex
in the case of exemption applications
(such as TMEA) LVE, LOREX)
e certain information provided i
ch notification is binding on the submitter
when the Agency approves the exemption application) checking a binding box in this notice does not by itself
prohibit the submitter from later deViating from the information (except chemical identity) reported in the form.

PMN FOTIn - Page 1 continued

PMN Fonn - Certification page (PMN pagel)

Public reporting burden for this collection of information is estimated to average 110 hours
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
ormation. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Chief, Information Policy Branch, PM-223,
U.s. Environmental Protection Agency, 401 M. St., S. W., Washington, D.C. 20460; and to the Office of Management and Budget, Paperwork Reduction Act
(2070-o012), Washington, D.C. 20503.
knowledge and belief:
A subsection la of this notice form intends to manufacture or import
ies solely for research and development, the substance
as of the date of submission.
ing with this notice all te
or control and a description of all other data
reasonably ascertainable by me as required by §720.50 of the Premanufacture
n Rule.
User Fee Certification

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ou are submitting a PMN, Intermediate PMN, Co
ation statement that applies:

check the following user fee

I, Section A has remitted the

specified in 40 CFR

The Company named in Part I, Section A has remitted the
40 CFR 700.43) in accordance with 40 CFR 700,45{b), or

or

for an Intermediate PMN (defined @

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).

LVEorLoREXCertification

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If you are submitting a low volume exemption (LVE) application in accordance with 40 CFR
release and low exposure exemption (LoREX)
following certification statements:
The manufacturer submitting this notice
other than in smal

ted meets all applicable exemption conditions.
this application is for an LVE'
commence manufacture of the exempted substan
expiration of the 30 day review period.

723.50{c){1), the manufacturer intends to
mmercial purposes within 1 year of the date of the

PMN Fonn - General infonnation page (PMN page 3)

Name of authorized official

Positio

Company
Mailing
(number an
State
CBI

1b. Agent (if applicable) [ Copy
Position

City

St

one Number
if

are submitting this notice as part of a joint submission, mark this box
CBI

1c. Joint Submitter (i
Name of

Position

CBI

2. Technical Contact (in U.s.) [
Name of authorized official
Company

Phone Number
3. Prenotice Communication Number

NONE

CBI

4. Previously Submitted Exemption No

NONE

CBI

5. Bona fide intent Notice Number

N

CBI

6. Type of Notice

1.

Manufacture Only

2.

Import Only

3.

Both

PMN Fonn - Header page for ID pages (PMN pages 4, 5 and 6)

. Chemical Type

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Complete either item 1 (Class 1 or 2 substances) PMN Page 4) and/or 2 (Polymers; PMN Page 5) as appropriate. Indicate
which section you intend to complete below.
1. Class 1 or 2 Substance
2. Polymer

PMN Fonn - PMN page 4

a. Class of Substance

Class 1

Class 2

CBI

b. Chemical Name

CAS Registry Number (if a number already exists for the substance)
CBI
Method 1 (CAS Inventory Expert Service)

Method 2 (Other Sources)

IES Order #

d. Molecular Formula
e. Chemical Structure Diagram

CBI

PMN Fonn - PMN page 4a

Class 2 Substance Details

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Fill in below for a class 2 substance. (I) List the immediate precursor substances with their respective CAS Registry
Numbers. (2) Describe the nature of the reaction or process. (3) Indicate the range of composition and the typical
composition (where appropriate). To claim information as confidential} bracket the specific information that you claim as
confidential {e. g. {cbi text})
e. (1) Precursor Substances

Check here to include an attachment for the precursor substances

e.(2) Nature of

ction

Check here to include an attachment for the nature of reaction
Range of Compositio

Check here to include an attachment for the range of composition

PMN Form - PMN page 5

2. Polymers (for a definition of polymer] see the Instruction Manual)

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