7710-25 Premanufacture Notice

CBI SUBMISSION

Cover Letter
This cover letter contains CBI.
Cover Letter goes here

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CBI SUBMISSION

PMN Page 1

PMN2021P1

Form Approved. O.M.B. No. 2070-0012. Approval Expires 12/31/2022

U.S. ENVIRONMENTAL PROTECTION AGENCY

EPA
When
completed,
send this
form to:

AGENCY USE ONLY

PREMANUFACTURE
NOTICE
FOR NEW CHEMICAL SUBSTANCES

If sending by Courier:
Office of Pollution Prevention and Toxics
Document Control Office (7407M)
US EPA, 1201 Constitution Ave NW
WASHINGTON, D.C. 20460
Contact Numbers: 202-564-8930/8940

If sending by US Mail:
Office of Pollution Prevention and Toxics
Document Control Office (7407M)
US EPA, 1200 Pennsylvania Ave NW
WASHINGTON, D.C. 20460

Total Number of Pages

•

Submission Report Number

TS Number

20
•
•

Date of receipt:

123456

GENERAL INSTRUCTIONS
You must provide all information requested in this form to the extent that it is known to or reasonably ascertainable by you. Make reasonable estimates if you do not have actual data.
Before you complete this form, you should read the “Instructions Manual for Premanufacture Notification” (the Instructions Manual is available from the Toxic Substances Control Act
(TSCA) Information Service by calling 202-554-1404, or faxing 202-554-5603).
If a fee has been remitted for this notice (40 CFR 700.45), indicate in the boxes above the TS fee identification number you have generated. Remember, your fee ID number must also
appear on your corresponding fee remittance. For mailing address information see the Help instructions in the e-PMN tool.

Part I – GENERAL INFORMATION
You must provide the currently correct Chemical Abstracts (CA)
Name of the new chemical substance, even if you claim the
identity as confidential. You may authorize another person to
submit chemical identity information for you, but your submission
will not be complete and the review will not begin until EPA
receives this information. A letter in support of your submission
should reference your TS fee identification number. For all
Section 5 Notice submissions (paper or electronic) you must
submit an original notice including all test data; if you claimed any
information as confidential, an original sanitized copy must also be
submitted.

Part II – HUMAN EXPOSURE AND ENVIRONMENTAL
RELEASE
If there are several manufacture, processing, or use operations to
be described in Part II, sections A and B of this notice, reproduce
the sections as needed.

TEST DATA AND OTHER DATA
You are required to submit all test data in your possession or control and to provide a
description of all other data known to or reasonably ascertainable by you, if these data are
related to the health and environmental effects on the manufacture, processing, distribution in
commerce, use, or disposal of the new chemical substance. Standard literature citations may
be submitted for data in the open scientific literature. Complete test data (written in English),
not summaries of data, must be submitted if they do not appear in the open literature. You
should clearly identify whether test data is on the substance or on an analog. Also, the
chemical composition of the tested material should be characterized. Following are examples
of test data and other data. Data should be submitted according to the requirements of
§720.50 of the Premanufacture Notification Rule (40 CFR Part 720).
Test Data (Check Below any included in this notice)

X

Environmental fate data

Part III – LIST OF ATTACHMENTS

Environmental effects data

Risk Assessments
Structure/activity relationships

Physical/Chemical Properties (A physical and chemical properties worksheet is
located on the last page of this form.)
Test data not in the possession or control of the submitter

OPTIONAL INFORMATION

TYPE OF NOTICE (Check Only One)

X

PMN (Premanufacture Notice)
SNUN (Significant New Use Notice)
TMEA (Test Marketing Exemption Application)
LVE (Low Volume Exemption) @ 40 CFR 723.50(c)(1)
LOREX (Low Release/Low Exposure Exemption) @ 40 CFR 723.50(c)(2)
LVE Modification
LOREX Modification
Mock Submission

CONFIDENTIALITY CLAIMS
You may claim any information in this notice as confidential. To
assert a claim on the form, mark (X) the confidential box next to
the information that you claim as confidential. To assert a claim in
an attachment, circle or bracket the information you claim as
confidential. If you claim information in the notices as confidential,
you must also provide a sanitized version of the notice, (including
attachments). For additional instructions on claiming information
as confidential, read the Instructions Manual.

X

Health effects data

For paper submissions, attach additional sheets if there is not
enough space to answer a question fully. Label each continuation
sheet with the corresponding section heading. In Part III, list these
attachments, any test data or other data and any optional
information included in the notice.

You may include any information that you want EPA to consider in
evaluating the new substance. On page 11 of this form, space has
been provided for you to describe pollution prevention and
recycling information you may have regarding the new substance.
“Binding” boxes are included throughout this form for you to
indicate your willingness to be bound to certain statements you
make in this section, such as use, production volume, protective
equipment . . . The intention is to reduce delays that routinely
accompany the development of consent orders or Significant New
Use Rules. Checking a "binding" box in a PMN does not by itself
prohibit the submitter from later deviating from the information
(except chemical identity) reported in the form; however, in the
case of exemption applications (such as TMEA, LVE, LOREX)
certain information provided in such notifications is binding on the
submitter when the Agency approves the exemption application,
especially if the production volume "binding" box is chosen in a
LVE.

Other Data

Mark (X) if pending Letter of Support

N
1
X

IS THIS A CONSOLIDATED PMN (Y/N)?
# of chemicals or polymers (Prenotice Communication # required, enter # on
p. 3).
Mark (X) if any information in this notice is claimed as confidential.

EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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The public reporting and recordkeeping burden for this collection of information is estimated to average 93 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 7710-25 to this address.

CERTIFICATION -- A printed copy of this signature page, with original signature, must be submitted
with CD or paper submission.

si

on

I hereby certify to the best of my knowledge and belief that all information entered on this form is complete and accurate.
I further certify that, pursuant to 15 U.S.C. § 2613(c), for all claims for protection for any confidential information made with this
submission, all information submitted to substantiate such claims is true and correct, and that it is true and correct that the
person submitting the claim has:
(i) taken reasonable measures to protect the confidentiality of the information;
(ii) determined that the information is not required to be disclosed or otherwise made available to the public under any other
Federal law
(iii) a reasonable basis to conclude that disclosure of the information is likely to cause substantial harm to the competitive
position of the person; and
(iv) 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.

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Additional Certification Statements:

The Company named in Part I, Section A is a “small business concern” as defined under 40 CFR 700.43 and will remit the
fee as specified in 40 CFR 700.45(c).

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X

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If you are submitting a PMN, SNUN, LoREX, LVE, or TMEA, check the following Fees Certification
statement that applies:

The Company named in Part I, Section A will remit the fee as specified in 40 CFR 700.45(c).

rS

This joint submission includes at least one Company which is a “small business concern” and at least one Company which is
not a “small business concern,” as defined under 40 CFR 700.43. The fee will be remitted with the joint submission. Any
remaining balance due for this joint submission is to be paid by the secondary submitter(s).
The company named in Part I, Section A is submitting a sustainable futures TME. The company has graduated from EPA's
Sustainable Futures program and is therefore exempt from fees for this sustainable futures TME.

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If you are submitting a Low Volume Exemption (LVE) application in accordance with 40 CFR 723.50(c)(1) or a
Low Release and Low Exposure Exemption (LoRex) application in accordance with 40 CFR 723.50(c)(2), check
the following certification statements:

ot

The manufacturer submitting this notice intends to manufacture or import the new chemical substance for commercial purposes,
other than in small quantities solely for research and development, under the terms of 40 CFR 723.50.

N

The manufacturer is familiar with the terms of this section and will comply with those terms; and

The new chemical substance for which the notice is submitted meets all applicable exemption conditions.

If this application is for an LVE in accordance with 40 CFR 723.50(c)(1), the manufacturer intends to commence manufacture of
the exempted substance for commercial purposes within 1 year of the date of the expiration of the 30 day review period.

Confidential

Signature and title of
Authorized Official (Original
Signature Required)

ES/Brooke E Plaisance

Date

EPA Form 7710-25 (12-19)

08/24/2021

X

Replaces previous editions of EPA Form 7710-25

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Part I -- GENERAL INFORMATION
Section A – SUBMITTER IDENTIFICATION
Mark (X) the "Confidential" box next to any subsection you claim as confidential

Person Submitting Notice (in U.S.)

Name of Authorized Official

(first)

Position

Not Applicable

Company

CDX Test Org

Mailing Address (number & street)

123 Main St

Confidential
(last)

Brooke

City

Virginia Beach

email

[email protected]

b.

Agent (if Applicable)

X
State

(first)

Name of Authorized Official

Plaisance

VA

Postal Code

(last)

Brooke

23462

Plaisance

Company

CDX Test Org

Mailing Address (number & street)

123 Main St
State

VA

Telephone
(include area code)

e-mail

[email protected]

c.

Joint Submitter (if applicable)

If you are submitting this notice as part of a joint submission, mark (X)
(first)

Name of Authorized Official

23462

3333333333
Confidential

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Company

rS

Mailing Address (number & street)
City

State

e-mail

Postal Code
Telephone
(include area code)

Technical Contact (in U.S.)

Position
Company

(first)

John

ot

X

456 Main St
State

Virginia Beach

VA

Postal Code

Telephone
(include area code)

N

e-mail

Doe

CDX Test Org

Mailing Address (number & street)
City

Confidential
(last)

fo

Name of Authorized Official

X

(last)

Position

2.

Postal Code

is

Virginia Beach

Confidential

m

City

si

Position

on

1a.

[email protected]

23462
5555555555

If you have had a prenotice communication (PC) concerning
this notice and EPA assigned a PC Number to the notice,
enter the number.

Mark (X) if none

Confidential

X

X

Mark (X) if none

Confidential

4.

If you previously submitted an exemption application for the
chemical substance covered by this notice, enter the
exemption number assigned by EPA. If you previously
submitted a PMN for this substance enter the PMN number
assigned by EPA (i.e. withdrawn or incomplete).

X

X

Mark (X) if none

Confidential

5.

If you have submitted a notice of Bona fide intent to
manufacture or import for the chemical substance covered
by this notice, enter the notice number assigned by EPA.

X

X

3.

6.

Type of Notice – Mark (X)
Manufacture Only

1.
Binding Option

X
X

Import Only

2.

3.

Both

Binding Option

EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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Part I – GENERAL INFORMATION -- Continued
You must provide a currently correct Chemical Abstracts (CA) name of the substance
based on current CA index nomenclature rules and conventions.
Mark (X) the “Confidential” box next to any item you claim as confidential

Section B – CHEMICAL IDENTITY INFORMATION:

Complete either item 1 (Class 1 or 2 substances) or 2 (Polymers) as appropriate. Complete all other items.
If another person will submit chemical identity information for you (for either Item 1 or 2), mark (X) the box at the right. Identify
the name, company, and address of that person in a continuation sheet.
1. Class 1 or 2 chemical substances (for definitions of class 1 and class
2 substances, see the Instructions Manual)

Class 1

Class 2

X

a. Class of substance - Mark (X)

CBI

X

b. Chemical name (Currently correct Chemical Abstracts (CA) Name that is consistent with TSCA Inventory listings for similar
substances. For Class 1 substances a CA Index Name must be provided. For Class 2 substances either a CA Index Name or CA
Preferred Name must be provided, which ever is appropriate based on current CA index nomenclature rules and conventions).

2-Propanol, 1-[(2-aminoethyl)amino]-

CAS Registry Number (if a number already exists for the substance)

123-84-2

c. Please identify which method you used to develop or obtain the specified chemical identity information reported in this notice: (check one).
Method 2
Method 1 (CAS Inventory Expert Service - a copy of the
IES Order
Identification report obtained from the CAS Inventory Expert
(Other
X
Number
Services must be submitted as an attachment to this notice)
Source)
Enter Attachment filename for Part I, Section B, 1. c.
d. Molecular formula

00123

X

e. For a class 1 substance, provide a complete and correct chemical structure diagram. For a class 2 substance, provide a correct
representative or partial chemical structure diagram, as complete as can be known, if one can be reasonably ascertained.

X

See Attachment (Original Document: 1 cgi-logo.png
)

Enter Attachment filename for Part I, Section B, 1. e.

EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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CBI SUBMISSION

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For a class 2 substance - (1) List the immediate precursor substances with their respective CAS Registry Numbers. (2) Describe
the nature of the reaction or process. (3) Indicate the range of composition and the typical composition (where appropriate).

Confidential

e. (1) List the immediate precursor substance names with their respective CAS Registry Numbers.

Enter Attachment filename for Part I, Section B, 1. e. (1)
e. (2) Describe the nature of the reaction or process.

Enter Attachment filename for Part I, Section B, 1. e. (2)
e. (3) Indicate the range of composition and the typical composition (where appropriate).

Enter Attachment filename for Part I, Section B, 1. e. (3)

EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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CBI SUBMISSION

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Part I -- GENERAL INFORMATION -- Continued

Section B -- CHEMICAL IDENTITY INFORMATION -- Continued

3. Impurities
(a) - Identify each impurity that may be reasonably anticipated to be present in the chemical substance as manufactured for commercial
purpose. Provide the CAS Registry Number if available. If there are unidentified impurities, enter “unidentified.”
(b) - Estimate the maximum weight % of each impurity. If there are unidentified impurities, estimate their total weight %.
CAS Registry
Maximum
ConfiImpurity (a)
Number
Percent %
dential
(a)
(b)

Propanoic acid, 2-hydroxy-, sodium salt (1:1)

72-17-3

70.0

Mark (X) this box if the data continues on the next page.
Enter Attachment filename for Part I, Section B, 3.
4. Synonyms - Enter any chemical synonyms for the new chemical identified in subsection 1 or 2.
Synonym Test,

Enter Attachment filename for Part I, Section B, 4.

X
X

Original Document: 2 epa-logo.png

5. Trade identification - List trade names for the new chemical substance identified in subsection 1 or 2.
Trade Name Test,

X
Enter Attachment filename for Part I, Section B, 5.
6. Generic chemical name - If you claim chemical identify as confidential, you must provide a generic name for your substance that reveals the
specific chemical identity of the new chemical substance to the maximum extent possible. Refer to the TSCA Chemical
Substance Inventory, 1985 Edition, Appendix B for guidance on developing generic names.

Enter Attachment filename for Part I, Section B, 6.
7. Byproducts - Describe any byproducts resulting from the manufacture, processing, use, or disposal of the new chemical substance. Provide the
CAS Registry Number if available.
CAS Registry Number
ConfiByproduct (1)
(2)
dential

Benzenethiol, 4-bromo-

106-53-6

Mark (X) this box if the data continues on the next page.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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PMN Page 6
Part I -- GENERAL INFORMATION – Continued

CBI SUBMISSION

Section B -- CHEMICAL IDENTITY INFORMATION -- Continued

2. Polymers (For a definition of polymer, see the Instructions Manual.)
a. Indicate the number-average weight of the lowest molecular weight composition of the polymer you intend to manufacture.
Indicate maximum weight percent of low molecular weight species (not including residual monomers, reactants, or solvents)
below 500 and below 1,000 absolute molecular weight of that composition.

Confidential

Describe the methods of measurement or the basis for your estimates:

Other (Specify Below)

GPC
Specify Other:

(ii) maximum weight % below 500 molecular
weight:

(iii) maximum weight % below 1000 molecular
weight:

on

(i) lowest number average molecular
weight:

Enter Attachment filename for Part I, Section B, 2. a.

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CAS Registry Number (1)

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b. You must make separate confidentiality claims for monomer or other reactant identity, composition information, and residual information. Mark
(X) the “Confidential” box next to any item you claim as confidential
(1) - Provide the specific chemical name and CAS Registry Number (if a number exists) of each monomer or other reactant used in the
manufacture of the polymer.
(2) - Mark (X) this column if entry in column (1) is confidential.
(3) - Indicate the typical weight percent of each monomer or other reactant in the polymer.
(4) - Choose “yes” from drop down menu if you want a monomer or other reactant used at two weight percent or less to be listed as part of
the polymer description on the TSCA Chemical Substance Inventory.
(5) - Mark (X) this column if entries in columns (3) and (4) are confidential.
(6) - Indicate the maximum weight percent of each monomer or other reactant that may be present as a residual in the polymer as
manufactured for commercial purposes.
(7) - Mark (X) this column if entry in column (6) is confidential.
Max
Typical Include in
Monomer or other reactant specific chemical name
CBI residual CBI
CBI composition identity
(1)
(6)
(4)
(3)
(7)
(5)
(2)

N

ot

CAS Registry Number (1)

CAS Registry Number (1)

CAS Registry Number (1)

CAS Registry Number (1)
Mark (X) this box if the data continues on the next page.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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c. Please identify which method you used to develop or obtain the specified chemical identity information reported in this notice
(check one).
Method 1 (CAS Inventory Expert Service
IES Order
Method 2
- a copy of the identification report obtained
Number
(other source)
from CAS Inventory Expert Service must be
submitted as an attachment to this notice)

CBI

Enter Attachment filename for Part I, Section B, 2. c.

CAS Registry Number (if a number already exists for the substance)

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on

d. The currently correct Chemical Abstracts (CA) name for the polymer that is consistent with TSCA Inventory listings for similar
polymers.

N

ot

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e. Provide a correct representative or partial chemical structure diagram, as complete as can be known, if one can be reasonably
ascertained.

Enter Attachment filename for Part I, Section B, 2. e.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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CBI SUBMISSION

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Part I -- GENERAL INFORMATION -- Continued

Section C -- PRODUCTION, IMPORT, AND USE INFORMATION:
The information on this page refers to consolidated chemical number(s):

X 1

2

3

4

5

6

Mark (X) the “Confidential” box next to any item you claim as confidential.

1. Production volume -- Estimate the maximum production volume during the first 12 months of production. Also estimate the maximum production
volume for any consecutive 12-month period during the first three years of production. Estimates should be on 100% new chemical substance basis.
For a Low Volume Exemption application, if you choose to have your notice reviewed at a lower production volume than 10,000 kg/yr, specify the
volume and mark (x) in the binding box. If granted, you are bound to this volume.
Maximum first 12-month production (kg/yr)
(100% new chemical substance basis)

5000

Maximum 12-month production (kg/yr)
(100% new chemical substance basis)

Binding Option
Mark (X)

Confidential

X

X

50000

Enter Attachment filename for Part I, Section C, 1.
CBI X
Original Document: 3 Hazard Logo.jpg
2. Use Information -- You must make separate confidentiality claims for the description of the category of use, the percent of production volume devoted
to each category, the formulation of the new substance, and other use information. Mark (X) the “Confidential” Box next to any item you claim as
confidential.
a. (1) --Describe each intended category of use of the new chemical substance by function and application.
(2) --Indicate your willingness to have the information provided in column (1) binding.
(3) --Mark (X) this column if entry column (1) is confidential business information (CBI).
(4) --Estimate the percent of total production for the first three years devoted to each category of use.
(5) --Mark (X) this column if entry in column (4) is confidential business information (CBI).
(6) --Estimate the percent of the new substance as formulated in mixtures, suspensions, emulsions, solutions, or gels as manufactured for
commercial purposes at sites under your control associated with each category of use.
(7) --Mark (X) this column if entry in column (6) is confidential business information (CBI).
(8) --Indicate % of product volume expected for the listed “use” sectors. Mark more than one box if appropriate. Mark (X) to indicate your
willingness to have the use type provided in (8) binding.
(9) --Mark (X) this column if entry(ies) in column (8) is (are) confidential business information (CBI).
% of substance expected per use
% in
Prod
Binding
Category of use (1)
CBI
(8)
CBI
FormCBI
uction
CBI
Option
(by function and application i.e. a dispersive dye for
ulation
%
Mark (X)
SiteConComBinding
finishing polyester fibers)
Industrial
limited
sumer*
mercial
Option
(9)
(7)
(5)
(6)
(4)
(3)
(2)

X

Testing Category of Use

100.0

X

100.0

X

10.0

50.0

15.0

X

25.0

* If you have identified a “consumer” use, please provide on a continuation sheet a detailed description of the use(s) of this chemical substance in
consumer products. In addition include estimates of the concentration of the new chemical substance as expected in consumer products and describe
the chemical reactions by which this substance loses its identity in the consumer product.

X

Mark (X) this box if the data continues on the next page.
b.

Generic use
description

If you claim any category of use description in subsection 2a as confidential, enter a generic description of that category.
Read the Instruction Manual for examples of generic use descriptions.

Testing Testing Test Test

CBI

Enter Attachment filename for Part I, Section C, 2. b.

3. Hazard Information -- Include in the notice a copy of reasonable facsimile of any hazard warning statement, label, material safety
data sheet, or other information which will be provided to any person who is reasonably likely to be exposed to this substance
regarding protective equipment or practices for the safe handing, transport, use, or disposal of the new substance. List in part III
hazard information you include.

Binding Option
Mark (X)

X

Mark (X) this box if you attach hazard information.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

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Continuation Sheet
ID

Field

Part I, Section C, 2.a. Additional Consumer Use Text

Category of Use: Testing Category of Use
Consumer Use: Testing Consumer Use : Testing Testing Test Test
Attachments:

Replaces previous editions of EPA Form 7710-25

EPA Form 7710-25 (12-19)

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Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE

CBI SUBMISSION

PMN2021P8

Mark (X) the “Confidential” box next to
any item you claim as confidential

Section A -- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER
X 1

The information on pages 8 and 8a refer to consolidated chemical number(s):

2

3

4

5

6

Complete section A for each type of manufacture, processing, or use operation involving the new chemical substance at industrial sites
you control. Importers do not have to complete this section for operations outside the U.S.; however, you may still have reporting
requirements if there are further industrial processing or use operations after import. You must describe these operations. See
instructions manual
1. Operation description
Confidential
a.1 Identity -- Enter the identity of the site at which the operation will occur.
Name

1A

Site address (number and
street)

804 E ST MARY BLVD

City
State

X

LAFAYETTE

County

LAFAYETTE PARISH

LA

ZIP code

70503

1.a.2 If the same operation will occur at more than one site, enter the number of sites. Identify the
additional sites on a continuation sheet, and if any of the sites have significantly different production
rates or operations, include all the information requested in this section for those sites as attachments.
Æ
Mark (X) this box if the data continues on the next page.
b. Type -Mark (X)

Manufacturing

Processing

X

1

X

X

Use

Confidential

c. Amount and Duration -- Complete 1 or 2 as appropriate

1. Batch

2. Continuous

Maximum kg/batch
(100% new chemical
substance)
1500.0

(2)

(3)

Batches/year

X
120.0

Maximum kg/day
(100% new chemical substance)

60.0
Hours/day

Mark (X) to indicate your willingness to
have your process description binding.

d. Process description
(1)

Hours/batch

Æ

Days/year

X

Diagram the major unit operation steps and chemical conversions. Include interim storage and transport containers (specify- e.g. 5 gallon
pails, 55 gallon drum, rail car, tank truck, etc.).
Provide the identity, the approximate weight (by kg/day or kg/batch on a 100% new chemical substance basis), and entry point of all starting
materials and feedstocks (including reactants, solvents, catalysts, etc.), and of all products, recycle streams, and wastes. Include cleaning
chemicals (note frequency if not used daily or per batch.).
Identify by number the points of release, including small or intermittent releases, to the environment of the new chemical substance. If
releasing to two media at the same step, assign a second release number for the second medium.

X
Process Description testing.

EPA Form 7710-25 (12-19)

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Confidential

Diagram of the major unit operation steps.

Enter Attachment filename for Part II, Section A, 1. d.

EPA Form 7710-25 (12-19)

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Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued
Section A -- INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER -- Continued
X 1
2
3
4
The information on pages 9 and 9a refer to consolidated chemical number(s):

5

6

2. Occupational Exposure -- You must make separate confidentiality claims for the description of worker activity, physical form of the new chemical
substance, number of workers exposed, and duration of activity. Mark (X) the “Confidential” box next to any item you claim as confidential.
(1) -- Describe the activities (i.e. bag dumping, tote filling, unloading drums, sampling, cleaning, etc.) in which workers may be exposed to the
substance.
(2) -- Mark (X) this column if entry in column (1) is confidential business information (CBI).
(3) -- Describe any protective equipment and engineering controls used to protect workers.
(4) -- Mark (X) this column if entry in column (3) is confidential business information (CBI).
(5) -- Indicate your willingness to have the information provided in column (3) binding.
(6) -- Mark (X) this column if entry in column (5) is confidential business information (CBI).
(7) -- Indicate the physical form(s) of the new chemical substance (e.g., solid: crystal, granule, powder, or dust).
(8) -- Mark (X) this column if entries in column (7) is confidential business information (CBI).
(9) -- Enter the % of the chemical that is a new substance (if part of a mixture) at the time of exposure.
(10) -- Indicate your willingness to have the information provided in column (8) binding.
(11) -- Mark (X) this column if entry in column (9) is confidential business information (CBI).
(12) -- Estimate the maximum number of workers involved in each activity for all sites combined.
(13) -- Mark (X) this column if entry in column (11) is confidential business information (CBI).
(14) -- Enter the maximum duration (14a) Hrs/Day or (14b) Days/Year.
(15) -- Mark (X) this column if entry in column (14a) or (14b) is confidential business information (CBI).

X

Engineering
Controls (3)

CBI
(4)

Binding
Option
Mark (X)

CBI

(5)

(6)

% new
Binding
Physical
Option
form(s) CBI substance
Mark (X)
(7)
(8)
(9)
(10)

X

X

Liquid

Testing
Protective
Equipment

# of
CBI Workers CBI
Exposed
(12)
(13)
(11)

is

(2)

Protective
Equipment/

80

X

4

X

Maximum Duration
Hrs/Day
(14a)

Days/Yr
(14b)

8

30

CBI
(15)

X

N

ot

fo

rS

ub

Sampling

CBI

m

Worker activity
(i.e., bag dumping,
filling drums)
(1)

Mark (X) this box if the data continues on the next page.
Enter Attachment filename for Part II, Section A on the bottom of page 9a.
EPA Form 7710-25 (12-19)

ion

Replaces previous editions of EPA Form 7710-25

Page 14

CBI SUBMISSION

PMN Page 9a

PMN2021P9A

3. Environmental Release and Disposal -- You must make separate confidentiality claims for the release number and the amount of the new chemical
substance released and other release and disposal information. Mark (X) the “Confidential” box next to each item you claim as confidential.
(1) -- Enter the number of each release point identified in the process description, part II, section A, subsection 1d(3).
(2) -- Mark (X) this column if entries in column (1) is confidential business information (CBI).
(3) -- Estimate the amount of the new substance released (a) directly to the environment or (b) into control technology (in kg/day or kg/batch).
(4) -- Mark (X) this column if entries in columns (3a) or (3b) are confidential business information (CBI).
(5) -- Identify the media (stack air, fugitive air (optional-see Instruction Manual), surface water, on-site or off-site land or incineration, POTW, or
other (specify)) to which the new substance will be released from that release point. (specify)) to which the new substance will be released from
that release point.
(6) -- Mark (X) this column if entries in column (5) is confidential business information (CBI).
(7) -- (a) Describe control technology, if any, and control efficiency that will be used to limit the release of the new substance to the environment.
For releases disposed of on land, characterize the disposal method and state whether it is approved for disposal of RCRA hazardous waste.
On a continuation sheet, for each site describe any additional disposal methods that will be used and whether the waste is subject to
secondary or tertiary on-site treatment. (b) Estimate the amount released to the environment after control technology (in kg/day).
(8) -- Mark (X) this column if entries in columns (7(a)) or (7(b)) are confidential business information (CBI).
(9) -- Identify the destination(s) of releases to water. Please supply NPDES (National Pollutant Discharge Elimination System) numbers for direct
discharges or NPDES numbers of the POTW (Publicly Owned Treatment Works). Mark (X) if the POTW name or NPDES # is confidential business
information (CBI).
Release
Number

CBI

(1)

(2)

123

X

Amount of New
Substance Released
(3a)

(3b)

100

CBI
(4)

X

Medium of release
e.g. Stack air
(5)

Surface Water

CBI
(6)

X

Control technology and efficiency (you may wish to
optionally attach efficiency data)
(7a)

Binding
Mark
(X)

Testing Test Test

(7b)

Test

CBI
(8)

X

Mark (X) this box if the data continues on the next page.

(9) Mark (X) the destination(s) of releases to water.

NPDES#

CBI

POTW--provide
name(s)
Navigable waterway- provide name(s)

Other--Specify
Enter Attachment filename for Part II, Section A.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

Page 15

PMN2021P10

CBI SUBMISSION

PMN Page 10

Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE – Continued
Section B -- INDUSTRIAL SITES CONTROLLED BY OTHERS
1
2
3
4
The information on pages 10 and 10a refer to consolidated chemical number(s):

5

6

Complete section B for typical processing or use operations involving the new chemical substance at sites you do not control. Importers do not have to
complete this section for operations outside the U.S.; however, you must report any processing or use activities after import. See the Instructions Manual.
Complete a separate section B for each type of processing, or use operation involving the new chemical substance. If the same operation is performed at
more than one site describe the typical operation common to these sites. Identify additional sites on a continuation sheet.

1(a). Operation Description -- To claim information in this section as confidential, bracket (e.g. {}) the specific information that you claim as
confidential.

(1) -- Diagram the major unit operation steps and chemical conversions, including interim storage and transport containers (specify - e.g. 5 gallon
pails, 55 gallon drums, rail cars, tank trucks, etc). On the diagram, identify by letter and briefly describe each worker activity.
(2) -- Either in the diagram or in the text field 1(b) below, provide the identity, the approximate weight (by kg/day or kg/batch, on an 100% new
chemical substance basis), and entry point of all feedstocks (including reactants, solvents and catalysts, etc) and all products, recycle
streams, and wastes. Include cleaning chemicals (note frequency if not used daily or per batch).
(3) -- Either in the diagram or in the text field 1(b) below, identify by number the points of release, including small or intermittent releases, to the
environment of the new chemical substance.
(4) -- Please enter the # of sites (remember to identify the locations of these sites on a continuation sheet):

Number of Sites

1(b). (Optional) This space is for a text description to clarify the diagram above.

Confidential

Confidential

Enter Attachment filename for Part II, Section B on the bottom of page 10a.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

Page 16

CBI SUBMISSION

PMN Page 10a

PMN2021P10A

2. Worker Exposure/Environmental Release
(1) -- From the diagram above, provide the letter for each worker activity. Complete 3-13 for each worker activity described.
(2), (4), (6), (8), (10), (12), (14), (17), (19) and (21) -- Mark (X) this column if any of the preceeding entries are confidential business information (CBI).
(3) -- Estimate the number of workers exposed for all sites combined.
(5) -- Estimate the typical duration of exposure per worker in (5a) hours per day and (5b) days per year.
(7) -- Describe physical form of exposure and any protective equipment and engineering controls, if any, used to protect workers.
(9) -- Provide the physical form of exposure.
(11) -- Enter the % new chemical substance (if in mixture).
(13) -- Estimate the percent of the new substance as formulated when packaged or used as a final product
(15) -- From the process diagram above, enter the number of each release point. Complete 9-13 for each release point identified.
(15) -- Estimate the amount of the new substance released (a) directly to the environment or (b) into control technology to the environment (in
kg/day or kg/batch).
(19) -- Describe media of release i.e. stack air, fugitive air (optional-see Instructions Manual), surface water, on-site or off-site land or incineration,
POTW, or other (specify) and control technology, if any, that will be used to limit the release of the new substance to the environment.
(14) -- Identify byproducts which may result from the operation.

Letter
of
Activity
(1)

Release
Number

CBI
(2)

# of
Workers
Exposed
(3)

CBI

Duration of
Exposure

CBI

(4)

(5a)

(6)

(5b)

Amount of New Substance Released

(15)

(16a)

(16b)

Protective
Equip./
Engineering
Controls
(7)

CBI

Physical
Forms

(8)

(9)

CBI
(10)

% new
substance
(11)

CBI
(12)

% in
Formulation

CBI

(13)

(14)

CBI

Media of Release & Control Technology

CBI

(17)

(18)

(19)

Mark (X) this box if the data continues on the next page.
(20) Byproducts:

(21) CBI

Enter Attachment filename for Part II, Section B.

EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

Page 17

PMN2021P11

CBI SUBMISSION

PMN Page 11

OPTIONAL POLLUTION PREVENTION INFORMATION
To claim information in the following section as confidential, bracket (e.g. {}) the specific information that you claim as confidential.
In this section you may provide information not reported elsewhere in this form regarding your efforts to reduce or minimize potential risks
associated with activities surrounding manufacturing, processing, use and disposal of the PMN substance. Please include new information
pertinent to pollution prevention, including source reduction, recycling activities and safer processes or products available due to the new chemical
substance. Source reduction includes the reduction in the amount or toxicity of chemical wastes by technological modification, process and
procedure modification, product reformulation, and/or raw materials substitution. Recycling refers to the reclamation of useful chemical components
from wastes that would otherwise be treated or released as air emissions or water discharges, or land disposal. Quantitative or qualitative
descriptions of pollution prevention, source reduction and recycling should emphasize potential risk reduction in addition to compliance with existing
regulatory requirements. The EPA is interested in the information to assess overall net reductions in toxicity or environmental releases and
exposures, not the shifting of risks to other media (e.g., air to water) or nonenvironmental areas (e.g., occupational or consumer exposure). To the
extent known, information about the technology being replaced will assist EPA in its relative risk determination. In addition, information on the
relative cost or performance characteristics of the PMN substance to potential alternatives may be provided.
Describe the expected net benefits, such as
(1) an overall reduction in risk to human health or the environment;
(2) a reduction in the generation of waste materials through recycling, source reduction or other means;
(3) a reduction in the use of hazardous starting materials, reagents, or feedstocks;
(4) a reduction in potential toxicity, human exposure and/or environmental release; or
(5) the extent to which the new chemical substance may be a substitute for an existing substance that poses a greater overall risk to human
health or the environment.
CBI
Information provided in this section will be taken into consideration during the review of this substance. See PMN
Instructions Manual and Pollution Prevention Guidance manual for guidance and examples.
X

This pollution prevention information contains CBI.
Optional Pollution Test

Enter Attachment filename for Pollution Prevention Page 11.

EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

Page 18

PMN2021P12

CBI SUBMISSION

PMN Page 12
Part III -- LIST OF ATTACHMENTS

Attach continuation sheets for sections of the form, test data and other data (including physical/chemical properties and
structure/activity information), and optional information after this page. Clearly identify the attachment and the section of the form
to which it relates, if appropriate. Number consecutively the pages of any paper attachments. In the Number of Pages column
below, enter the inclusive page numbers of each attachment for paper submissions or enter the total number of pages for each
attachment for electronic submissions. Electronic attachments can be identified by filename.
Mark (X) the “Confidential” box next to any attachment name or filename you claim as confidential. Read the Instructions Manual
for guidance on how to claim any information in an attachment as confidential. You must include with the sanitized copy of the
notice form a sanitized version of any attachment in which you claim information as confidential.
#

1

Attachment Name

Attachment Test

Attachment Filename

epa-logo.png

Number
of Pages

1

Associated
PMN Section
Number

Synonyms Section (Test Chemical
Alias)

2

Testing Testing Testing

Hazard Logo.jpg

1

Production Information Section (Test
Chemical Alias)

3

Attachment Description Test

cgi-logo.png

1

Class 1 or 2 Substances Chemical
Structure Diagram (Test Chemical

CBI

X

X

Mark (X) this box if the data continues on the next page.
EPA Form 7710-25 (12-19)

Replaces previous editions of EPA Form 7710-25

Page 19

CBI SUBMISSION
PMN2021P13

X

X

500

Page 20

Estimate

X

PMN Page 14

PMN2021P3

CBI SUBMISSION

Part IV -- CBI Substantiation
This substantiation contains CBI:

Yes

X

No

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)

Submitting Official Confidential Business Information Substantiation
Yes No CBI

A. Applicable only to General CBI Claims
(i) Will disclosure of the information claimed as confidential likely cause substantial harm to your business's
competitive position? If you answered yes, describe the substantial harmful effects that would likely result to
your competitive position if the information is disclosed, including but not limited to how a competitor could
use such information, and the causal relationship between the disclosure and the harmful effects.

X

X

test
(ii) Has your business taken precautions to protect the confidentiality of the disclosed information? If yes, please explain and

identify the specific measures, including but not limited to internal controls, that your business has taken to protect the
information claimed as confidential. If the same or similar information was previously reported to EPA as non-confidential
(such as in an earlier version of this submission), please explain the circumstances of that prior submission and reasons
for believing the information is nonetheless still confidential.

X

test
(iii) (A) Is any of the information claimed as confidential required to be publicly disclosed under any other Federal law? If
yes, please explain.

X

X

test
(iii) (B) Does any of the information claimed as confidential otherwise appear in any public documents, including (but not limited
to) safety data sheets; advertising or promotional material; professional or trade publications; state, local, or Federal
agency files; or any other media or publications available to the general public? If yes, please explain why the
information should be treated as confidential.

X

test
(iii) (C) Does any of the information claimed as confidential appear in one or more patents or patent applications? If yes,
provide the associated patent number or patent application number (or numbers) and explain why the information should
be treated as confidential.

X

test
(iv) Is the claim of confidentiality intended to last less than 10 years (see TSCA section 14(e)(1)(B))? If yes, please indicate the
number of years (between 1-10 years) or the specific date after which the claim is withdrawn.

test
Page 21

X

X

PMN2021P3

CBI SUBMISSION

PMN Page 15

(v) Has EPA, another federal agency, or court made any confidentiality determination regarding information associated with
this chemical substance? If yes, please provide the circumstances associated with the prior determination, whether the
information was found to be entitled to confidential treatment, the entity that made the decision, and the date of the
determination.

X

test
Additional comments:

B. APPLICABLE ONLY TO A SPECIFIC CHEMICAL IDENTITY CBI CLAIM

Yes No CBI

Chemical Claim: Chemical Substance Identity – Applicable only to LVE/LOREX/Mock PMN submissions

(i) Is this chemical substance publicly known (including by your competitors) to be in U.S. commerce? If yes, please explain
why the specific chemical identity should still be afforded confidential status (e.g., the chemical substance is publicly known
only as being distributed in commerce for research and development purposes, but no other information about the current
commercial distribution of the chemical substance in the United States is publicly available). If no, please complete the
certification statement:

X

I certify that on the date referenced I searched the internet for the chemical substance identity (i.e., by both chemical
substance name and CASRN). I did not find a reference to this chemical substance that would indicate that the chemical
is being manufactured or imported by anyone for a commercial purpose in the United States. [provide date].

test
(ii) Does this specific chemical substance leave the site of manufacture (including import) in any form, e.g., as a
product, effluent, emission? If yes, please explain what measures have been taken to guard against the discovery of
its identity.

X

X

test
(iii) If the chemical substance leaves the site in a form that is available to the public or your competitors, can the chemical
identity be readily discovered by analysis of the substance (e.g., product, effluent, emission), in light of existing technologies
and any costs, difficulties, or limitations associated with such technologies? Please explain why or why not.

X

test
(iv) Would disclosure of the specific chemical identity release confidential process information? If yes, please explain.

X

X

test
Additional comments:

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

Date

Page 22

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).

Page 23