Form 6300-3

Page

1 of 2

OMB Control No.
2070-0174

United States Environmental Protection Agency
Washington, D.C. 20460
REQUIREMENTS STATUS AND REGISTRANT'S RESPONSE

Expiration Date
12/31/2025

Paperwork Reduction Act Notice: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et. seq. OMB Control No. 2070-0174. Responses to this collection of information are
mandatory 40 CFR 158. An agency may not conduct or sponsor, an 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 20 to 8128 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.
INSTRUCTIONS: Please type or print in ink. Please read carefully the attached instructions and supply the information requested on this form. Use additional sheet(s) if necessary.
1. Company Name and Address

2. Case # and Name

3. Date and Type of DCI and Number

[Company Name]

[Case #] [Chemical Name]

[Date email sent]
GENERIC
ID # GDCI-[GDCI #]

[Company Address]

4. Guideline
Requirement
Number

5. Study Title

[Guideline No]

Initial to indicate certification as to information on this page (full text of certification is on page one)

P
R
O
T
O
C
O
L

Progress
Reports

1

2

6. Use
Pattern

3

7. Test
Substance

8. Time
Frame
(Months)

9. Registrant
Response

10. 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, imprisonment or both under applicable law.
Signature and Title of Company's Authorized Representative

11. Date

12. Name of Company

13. Phone Number

EPA Form 6300-3