Form ESA and Authorizat ESA and Authorizat Authorization and Verification for Section 5 Notice Supp

Form Approved. O.M.B. Nos. 2070-0012 and 2070-0038.

AUTHORIZATION AND VERIFICATION FOR SECTION 5 NOTICE SUPPORT SUBMITTER

BY COMPANY AUTHORIZING OFFICIAL

Authorized Official Information

I am an authorizing official and an electronic signature holder in U.S. EPA’s CDX for the organization listed below, and verify that the person identified as the electronic signature holder below is authorized to submit only supplemental PMN documents (i.e., all support documents except for a Letter of Support) on behalf of my organization.
Name of Authorized Official:
Company Name:
Address:
City, State, Zip:
Signature		Date

Electronic Signature Holder for Submission of Supplemental Information

I acknowledge by my signature below that the accuracy of the statements in all electronic submissions reflect my best prediction of the anticipated facts regarding the chemical substance(s) described therein. Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18USC 1001. I also acknowledge that I am authorized to submit only supplemental PMN documents (i.e., all support documents except for a Letter of Support) on behalf of the organization listed above.
Name of Electronic Signature Holder:
Company Name:
Address:
City, State, Zip:
Country:			Province:
Signature				Date

PLEASE SEND THIS DOCUMENT AS SOON AS POSSIBLE TO:

By U.S. Postal Service: By Hand Delivery or Courier:

PMN CDX Registration Coordinator (7407M) PMN CDX Registration Coordinator

U.S. Environmental Protection Agency U.S. EPA- OPPT/CBIC

Office of Pollution Prevention and Toxics EPA East Building, Room 6428

Ariel Rios Building 1201 Constitution Ave, NW

1200 Pennsylvania Ave, NW Washington, DC 20004-3302

Washington, DC 20460 202-564-8930; 202-564-8940