9600-033 Polymer Exemption

OMB Control No. 2070-0012
Expires 12/31/2022

Polymer Exemption
Chemical Safety Act Certification
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.

on

Any knowing and willful misrepresentation is subject to criminal penalty pursuant to 18 U.S.C. § 1001.
Polymer Exemption Certification
I certify, under penalty of law, that the following is true:

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I certify that all of the chemical substances I am reporting in this notification were: manufactured (which includes imports) for
a commercial purpose other than for research and development; meet the definition of a polymer in 40 CFR 723.250(a); are
not specifically excluded from the exemption as stated in 40 CFR 723.250(d); and meet the conditions of the exemption as
defined in 40 CFR 723.250(e).
General Form Information

Polymer Exemption-20210510-13:45:41 EST

Prefix

First Name

Organization Name

Mary Kay

Phone Number

7032276159

Email Address

[email protected]

Last Name

Suffix

Falaiye

ot

7888 E Hill dr

Leesburg

State

Postal Code

Country

VA

22153

US

N

Submitting on Behalf of Company (If Applicable)
Prefix

X

CBI

rS

Not Applicable

City

888

fo

Job Title

Mailing Address 2

2020

Middle Initial

Carolina

Mailing Address 1

Number of Polymers

ub

Submitter Information

Reporting Year

m

Form Alias

X

CBI

First Name

CBI
Middle Initial

Last Name

Suffix

Job Title
Company Name
Phone Number
Email Address
Mailing Address 1
Mailing Address 2
City

EPA Form Number 9600-033

State

Postal Code

Page 1

Country

CBI

OMB Control No. 2070-0012
Expires 12/31/2022

Manufacturer Information

X

CBI

Organization Name

Mary Kay

Phone Number

7032276159 X 4025785

Email Address

[email protected]

Mailing Address 1

7888 E Hill dr

Mailing Address 2
State

Postal Code

Country

Leesburg

VA

22153

US

Technical Contact Information
Prefix

on

City

X

CBI

First Name

Middle Initial

Last Name
Falaiye

Organization Name

Mary Kay

Phone Number

7032276159 X 4025785

Email Address

[email protected]

Mailing Address 1

7888 E Hill dr

Mailing Address 2
State

Leesburg

VA

Postal Code

Country

22153

US

rS

City

m

test

ub

Job Title

is

si

Carolina

Suffix

N

ot

fo

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
2070-0012). Responses to this collection of information are mandatory for certain persons, as specified at 40 CFR 721 and 725.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to
be between 16.97 to 525.85 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 to the Regulatory Support Division
Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed form to this address.

EPA Form Number 9600-033

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OMB Control No. 2070-0012
Expires 12/31/2022

GENERAL INFORMATION -- Continued
CHEMICAL IDENTIFICATION INFORMATION
Polymer Information
Exemption Criteria
Exemption Criteria (e1)
Atomic Elements

CBI

Atomic Element

Weight Percent

Boron (B)

50.0

Lowest number average molecular
weight

Maximum weight % below 500 molecular
weight
Monomers and Other Reactants

CAS Reg #

CBI

% Typical Comp

Maximum weight % below 1000 molecular
weight

Include Identity

N

ot

fo

rS

ub

m

is

CA Index Name

CBI

on

Measurement Description

si

Method of Measurement

EPA Form Number 9600-033

Page 3

CBI

Maximum Residual

CBI

CBI

OMB Control No. 2070-0012
Expires 12/31/2022

Attachments List
File Name

Document Type

Description

CBI

Section Title

N

ot

fo

rS

ub

m

is

si

on

#

EPA Form Number 9600-033

Page 4

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OMB Control No. 2070-0012
Expires 12/31/2022
CBI SUBMISSION

Substantiation - Applicable to Any Claim
(i) Please specifically explain what harm to the competitive position of your business would be likely to result from the release of the information
claimed as confidential. How would that harm be substantial? Why is the substantial harm to your competitive position likely (i.e., probable) to be
caused by release of the information rather than just possible? If you claimed multiple types of information to be confidential (e.g. site information,
exposure information, environmental release information, etc.), explain how disclosure of each type of information would be likely to cause substantial
harm to the competitive position of your business.

CBI:

Yes
:No

✔

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.

CBI:

Yes
:No

✔

Test
CBI:

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

Yes
:No

✔

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.

CBI:

Yes
:No

✔

Test
(iii) (C) Has a patent been published for the chemical identity you claim confidential? What chemical identity information is not revealed by the patent?
How is release of that specific information likely to cause substantial competitive harm? And failure to explain this harm may lead to denial of your
confidentiality claim.

CBI:

Yes
:No

✔

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.

CBI:

Yes
:No

✔

Test
(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.

CBI:

Yes
:No

✔

Test
Certification
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 of 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 I have:
(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.
Signature of authorized official: William Brigman

Date: 2021-08-24

Page 2

EPA Form Number 9600-033