Form ESA and Authorizat ESA and Authorizat Verification of Company Authorizing Official

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

VERIFICATION OF COMPANY AUTHORIZING OFFICIAL

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.

Authorized Official Signature

I am BOTH the company authorizing official and the electronic signature holder in U.S. EPA’s CDX, and verify that I am authorized to submit any document on the company’s behalf.
Name of Authorized Official:
Company Name:
Address:
City, State, Zip
Province: (for non-domestic Letter of Support officials)
Country: (for non-domestic Letter of Support officials)
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