Form EPA Form No. 6300- EPA Form No. 6300- Initial Response Form for Individual Order Recipients (A

Tier 1 Screening of Certain Chemicals Under the Endocrine Disruptor Screening Program (EDSP)

2249.03_EPA Form 6300-05

Order Recipients - Manufacturers and Importers of Pesticide Inert Ingredients

OMB: 2070-0176

Document [pdf]
Download: pdf | pdf
Attachment D - (1)

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

OMB Control No.
2070-[Insert]

Endocrine Disruptor Screening Program (EDSP)
FFDCA §408(p) Order/FIFRA §(3)(c)(2)(B) DATA CALL-IN (DCI)
INITIAL RESPONSE FORM for INDIVIDUAL ORDER RECIPIENTS
Paperwork Reduction Act Notice: The public reporting burden for this collection of information is estimated to average 1 hour per response. Send
comments regarding the burden estimate to: Director, Collection Strategies Division (2822T), U.S. Environmental Protection Agency, Washington, DC
20460. Do not send the completed form to this address – follow the mailing instructions in the Order.

PART 1

Recipient Information (From the Order/DCI – To be Completed by EPA):

1.1. Order/DCI Info:

A. Order/DCI #:

B. Date Issued:

1.2. Company Name:

C. Initial Response Due:
1.3. Address:

1.4. Contact Person:

1.5. Chemical Info:

PART 2

A. Chemical #:

B. Chemical Name:

C. Company #(s):

Recipient’s Initial Response:

(Please refer to the Order/DCI for more information about response options, as well as detailed
instructions on how to comply with the Order.)

€ 2.1. I will generate new data or am citing/submitting existing data.
For each assay, check the appropriate box in the following table and follow Order instructions to attach required documentation.
A. I will generate new data.
B. I am citing existing data.
C. I am submitting existing data.
D. I am entering (or offering to enter) into an agreement to form a consortium to provide the data. Consortia must provide separate initial response
within 150 calendar days from issuance of the Order/DCI (see Initial Response Form for Consortium/Task Force at www.epa.gov/xxxxxxxxxxxx. )
Assays:
A
B
C
D
See attached documentation.
€ € € € …
2.1.1. Amphibian Metamorphosis (Frog)
€ € € € …
2.1.2. Androgen Receptor Binding (Rat Prostate)
€ € € € …
2.1.3. Aromatase (Human Recombinant)
€ € € € …
2.1.4. Estrogen Receptor Binding
€ € € € …
2.1.5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))
€ € € € …
2.1.6. Fish Short-term Reproduction
€ € € € …
2.1.7. Hershberger (Rat)
€ € € € …
2.1.8. Female Pubertal (Rat)
€ € € € …
2.1.9. Male Pubertal (Rat)
€ € € € …
2.1.10. Steroidogenesis (Human Cell Line – H295R)
€ € € € …
2.1.11. Uterotrophic (Rat)

€ 2.2. I am not subject to the Test Order/DCI. … See attached documentation.
These Response Options Apply Only to Registered Pesticides:
€ 2.3. I intend to voluntarily cancel the pesticide registration(s). … See attached documentation.
€ 2.4. I intend to reformulate the product(s) to exclude this chemical from the formulation. … See attached documentation.
€ 2.5. I am claiming a Formulators’ Exemption. … See attached documentation.
These Response Options Apply Only to Chemicals that are Other Ingredients (aka inerts):
€ 2.6. I have/am in the process of discontinuing the manufacture/import of this chemical. … See attached documentation.
€ 2.7. I do not and will not sell my chemical for use as an inert ingredient to the pesticide market. … See attached documentation.

PART 3

3.1. 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 fine or imprisonment or both under applicable law.

3.2. Company’s Authorized Representative:
Signature:

3.3. Date:

3.4. Phone Number:
Name and Title (Please Print or Type):
Email address:
Submit Completed Form By:
• Mail To: Document Processing Desk (SRRD-EDSP), Office of Pesticide Programs (7504P), U.S. Environmental Protection Agency, 1200
Pennsylvania Ave. NW, Washington, D.C. 20460
Part 4
• Deliver To: Document Processing Desk (SRRD-EDSP), Office of Pesticide Programs (7504P), U.S. Environmental Protection Agency,
One Potomac Yard (South Bldg.), 2777 S. Crystal Dr., Arlington, VA. Deliveries are only accepted 8:30 a.m. to 4 p.m., Monday through
Friday, excluding legal holidays.
EPA Form No. 6300-05


File Typeapplication/pdf
File TitleMicrosoft Word - EDSP-IRF-Individuals-2009-04-03.doc
AuthorAhofmann
File Modified2012-10-23
File Created2009-04-08

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