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EPA

U.S. Environmental Protection Agency
NOTICE OF ACTIVITY OF MANUFACTURE,
IMPORT, OR PROCESSING - FORM A

Submission Date:

2018-07-18

Revised Date:

Part I - Submitter Identification
Name of Authorized Official
(first)

Mailing Address (street, city, zip code)

CBI*

X

(last)
123 Main Street , City, WA, 12345

Manufacturer,
Importer,
Processor (in U.S.)

C

Technical Contact
(in U.S.)

G
Company Name

Mailing Address (street, city, zip code)

Christest

123 Main Street , City, WA, 12345

Name

Telephone Number

(first)
C

2025640710

(last)

X

X

G

*CBI refers to the term "Confidential Business Information." Mark (X) in the CBI box(es) if the submitter information is to be held confidential.

Part II - Chemical Substance Identity
CASRN

TSCA Inventory Chemical Name (if specific chemical identity is not CBI)

Accession
Number

Generic Chemical Name (if specific chemical identity is CBI)

80489

Ethylene interpolymer (PROVISIONAL)

Part III - Status of Confidential Chemical Substance Identity
X

I am seeking to maintain an existing claim of confidentiality for the specific chemical identity, as listed on the TSCA Inventory.
I am not seeking to maintain an existing claim of confidentiality for the specific chemical identity, as listed on the TSCA Inventory.

Part IV - Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision and the information contained therein, to
the best of my knowledge, is true, accurate, and complete. I also certify that I have manufactured, imported, or processed the above chemical substance
between the dates of June 21, 2006 and June 21, 2016. I am aware it is unlawful to knowingly submit incomplete, false and/or misleading information, and
there are significant criminal penalties for such unlawful conduct, including the possibility of fine and imprisonment.
Signature of authorized official:

Date:

Form A is for retrospective reporting. Domestic manufacturers and importers must submit a completed notice not later than 180 calendar days after August
11, 2017. Processors can voluntarily submit a completed notice not later than 420 calendar days after August 11, 2017. Requests to maintain an existing CBI
claim for specific chemical identity must be substantiated according to the Review Plan required under TSCA (not yet published, as of August 11, 2017), but
may be substantiated at the time this notice is submitted. Assertions of CBI claims for information other than specific chemical identity must be substantiated
at the time this notice is submitted.
The public reporting and recordkeeping burden for this collection of information is estimated to average 5.7 hours per response. Send comments on the
Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including
through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed EPA Form 9600-05 to
this address.

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Part V - CBI SUBSTANTIATION
This substantiation contains CBI:

Yes

No

X

Pursuant to TSCA section 14(c)(3), you must substantiate any CBI claims for information elements other than specific chemical identity at the time this notice is
submitted. EPA guidance for complying with TSCA section 14(c)(3) may be found at https://www.epa.gov/tsca-cbi/substantiating-cbi-claims-under-tsca-timeinitial-submission. You may also substantiate a request to maintain an existing CBI claim for a specific chemical identity at the time this notice is submitted,
but this is not required. Rather, you must substantiate the existing CBI claim for the specific chemical identity by the deadline established in a forthcoming
Review Plan, to be promulgated at a later date in accordance with TSCA section 8(b)(4)(C).
If you do not assert a CBI claim at time of submission of this form, or otherwise fail to assert a proper CBI claim (i.e., by failing to substantiate your CBI claim or
not providing a certification statement), the information shall be treated as not subject to a CBI claim, and may be made public without further notice. If a single
substantiation response applies for all or a class of information claimed as CBI, you should indicate this in your substantiation response. If different
substantiation responses are necessary to support CBI claims for different information types, you should provide separate substantiation responses for each
information type, clearly identifying the information for which each substantiation applies in the free text boxes (e.g. Question A.1. or 2) or in the additional
information box at the end of this form.
Information element(s) that you identified as CBI in previous parts:
X

Name of Authorized Official/Mailing address (Part I)

X

Company Name/Mailing Address (Part I)

X

Technical Contact/Telephone Number (in U.S.) (Part I)

X

Specific Confidential Chemical Identity (as listed on the TSCA Inventory) (Part II/III)

A. APPLICABLE TO ANY CBI CLAIM
1. Do you believe that the information is exempt from substantiation pursuant to TSCA section
14(c)(2)i?
If you answered yes, you must individually identify the specific information claimed as confidential
and specify the applicable exemption(s).
If the Agency disagrees with this assertion, you may be asked to provide additional information to
support your claim.

X Yes
No

Substantiated in communication sent to EPA 1/1/2018.
2. Will disclosure of the information likely result in substantial harm to your business's competitive
position?
If you answered yes, please describe with specificity the substantial harmful effects that would likely
result to your competitive position if the information is made available to the public.
If, for example, it is not publicly known that the submitter manufactures, imports or processes the
reported chemical, describe with specificity the harmful effects that would result if this information
were made available to the public. If you are claiming technical contact name or name of authorized
official as CBI, describe with specificity the harmful effects that would result if this information were
made available to the public.

X Yes
No

If you are claiming multiple information elements as CBI, please provide information for EACH element you identified above.
Previously substantiated in PMN P-14-0001.

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3. To the extent your business has disclosed the information to others (both internally and externally), what precautions
has your business taken? Please identify the measures or internal controls your business has taken to protect the
information claimed as confidential.
1. Non-disclosure agreement required prior to access.
2. Access is limited to individuals with a need-to-know.
3. Information is physically secured (e.g. locked in room or cabinet) or electronically
secured (encrypted, password protected, etc.).
4. Other internal control measure(s). If yes, please explain.

X Yes

No

X Yes

No

X Yes

No

X Yes

No

These claims were previously substantiated in 8(e) submission 8EHQ-10-0003
4. Does the information appear in any public documents, including (but not limited to) safety data
sheets, advertising or promotional material, professional or trade publication, or any other media or
publications available to the general public?

X Yes
No

If you answered yes, please explain why the information should be treated as confidential.
This reasoning was previously identified in CDR-2006-12345.
5. Is the claim of confidentiality intended to last less than 10 years (see TSCA section 14(e)(1)(B)ii)? If so, please
indicate the number of years (between 1-10 years) or the specific date/occurrence after which the claim is withdrawn.
I don't want to substantiate this information so there!
6. Has EPA, another federal agency, or court made any confidentiality determination regarding
information associated with this chemical substance?

X Yes

If you answered yes, please explain the outcome of that determination and provide a copy of the
previous confidentiality determination or any other information that will assist in identifying the prior
determination.

No

U.S. EPA
Additional comments:

B. APPLICABLE ONLY TO A SPECIFIC CHEMICAL IDENTITY CBI CLAIM
1. Are you providing a substantiation at this time to maintain a specific confidential chemical identity as
CBI?
X Yes

If you answered yes, please respond to questions below and in Section A.
If you answered no, please leave all questions below blank. You must substantiate by the deadline
established in a forthcoming Review Plan, to be promulgated at a later date in accordance with
TSCA section 8(b)(4)(C).

No

This is where a previously blank chemical substantiation or reference to previous substantiation reasoning would be located.
2. Is the confidential chemical substance publicly known to have ever been offered for commercial distribution in the United States?
If you answered yes, please explain why the information should be treated as confidential.

X Yes
No

This is where a previously blank chemical substantiation or reference to previous substantiation reasoning would be located.
Additional comments:
This is where additional information on previously blank chemical substantiations or references to previous substantiation reasoning would be located.

C. CERTIFICATION
I certify that all claims for confidentiality made or sought to be maintained with this submission are true and correct, and all information submitted herein to
substantiate such claims is true and correct. I further certify that it is true and correct that:
(i) My company has taken reasonable measures to protect the confidentiality of the information;
(ii) I have determined that the information is not required to be disclosed or otherwise made available to the public under any other Federal law;
(iii) I have a reasonable basis to conclude that disclosure of the information is likely to cause substantial harm to the competitive position of my company;
and
(iv) I have a reasonable basis to believe that the information is not readily discoverable through reverse engineering.
Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18 U.S.C. § 1001.
Signature of authorized official
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i TSCA Section 14(c)(2) states:

Information generally not subject to substantiation requirements
Subject to subsection (f), the following information shall not be subject to substantiation requirements under paragraph (3):
(A) Specific information describing the processes used in manufacture or processing of a chemical substance, mixture, or article.
(B) Marketing and sales information.
(C) Information identifying a supplier or customer.
(D) In the case of a mixture, details of the full composition of the mixture and the respective percentages of constituents.
(E) Specific information regarding the use, function, or application of a chemical substance or mixture in a process, mixture, or article.
(F) Specific production or import volumes of the manufacturer or processor.
(G) Prior to the date on which a chemical substance is first offered for commercial distribution, the specific chemical identity of the chemical substance, including the chemical
name, molecular formula, Chemical Abstracts Service Registry number, and other information that would identify the specific chemical substance, if the specific chemical identity
was claimed as confidential at the time it was submitted in a notice under section 2604 of this title.
ii TSCA section 14(e)(1)(B) states

(B) in the case of information other than information described in subsection (c)(2)—
(i) for a period of 10 years from the date on which the person asserts the claim with respect to the information submitted to the Administrator; or
(ii) if applicable before the expiration of such 10-year period, until such time as—
(I) the person that asserted the claim notifies the Administrator that the person is withdrawing the claim, in which case the information shall not be protected from
disclosure under this section; or
(II) the Administrator becomes aware that the information does not qualify for protection from disclosure under this section, in which case the Administrator shall take
any actions required under subsections (f) and (g).

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