0277.20 Attachment H

0277-20_ss_Attachment H.pdf

Application for New and Amended Pesticide Registration (Renewal)

0277.20 Attachment H

OMB: 2070-0060

Document [pdf]
Download: pdf | pdf
Form approved. OMB No. 2070-0060, 2070-0057, 2070-0107, 2070-0122, 2070-0164.

United States

Environmental Protection Agency
Washington, DC 20460

Formulator’s Exemption Statement
(40 CFR 152.85)

Applicant’s Name and Address

EPA File Symbol/Registration Number

Product Name

Date of Confidential Statement of Formula (EPA Form 8570-4)

As an authorized representative of the applicant for registration of the product identified above, I certify that:
(1) This product contains the following active ingredient(s):

(2) Of these, each active ingredient listed in paragraph (4) is present solely as the result of the use of that active ingredient in the manufacturing,
formulation or repackaging another product which contains that active ingredient which is registered under FIFRA Section 3, is purchased by
us from another person and meets the requirements of 40 CFR section 158.50(e)(2) or (3). 40 CFR Section 152.85(c)(2) or (3).
(3) Indicate by checking (A) or (B) below which paragraph applies:

 (A) An accurate Confidential Statement of Formula (EPA FORM 8570-4) for the above identified product is attached to this statement.
That formula statement indicates, by company name, registration number, and product name, the source of the active ingredient(s) listed in
paragraph (1).
OR



(B) The Confidential Statement of Formula (CSF)(EPA Form 8570-4) referenced above and on file with the EPA is complete, current, an
accurate and contains the information required on the current CSF.

(4) The following active ingredients in this product qualify for the formulator’s exemption.

Source
Active Ingredient

Signature

EPA Form 8570-27 (Rev. 06-2004)

Product Name

Name and Title

Registration Number

Date

Copy 1 – EPA
Copy 2 - Applicant copy

Paperwork Reduction Act Notice
The public reporting burden for this collection of information is estimated to average 1.5. hours per response,
including familiarization with the form, organizing the necessary information, and completing the form. Send
any comments regarding the burden estimate or any other aspect of this collection of information to: Director,
Collection Strategies Division (2822T), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue,
N.W., Washington, DC 20460. Do not send the completed form to this address.

EPA Form 8570-27 (Rev. 06-2004) Reverse Copy 1 - EPA Copy 2 - Applicant copy


File Typeapplication/pdf
File TitleUS EPA, OPP Registration Form, Formulator's Exemption Statement
AuthorUS EPA, OPP, Registration Division
File Modified2020-05-18
File Created2004-05-11

© 2024 OMB.report | Privacy Policy