Form 9600-049 CBI Substantiation

OMB Control Number 2070-0185 expires 9/30/2024

Third-Party Certifier Annual Report
Unique Form ID: TPC-AR-40639
Reporting Year

2023

Shared with CARB?

N

List of Panel Producers
Panel Producer - 1
Panel Producer Name

Test Producer

Panel Producer Address

1234 Test Street, Suite 200, City, 55555, ANDORRA

CBI

Panel Producer - 1: Product Information
Product Name

test 1

Product Type

test 1

Resin Type
Panel Producer - 1: Product Information: Lot - 1
Test Date

12/30/2022

Lot Number- 1

500000

Test Method
method 1
Volume (in Cubic Meters)

150000

Result of Re-Certification Testing
pass
Description of Disposition of Affected Product
test
Failed Quarterly Test

TPC-FQT-31193

QCL Exceedance

TPC-QCLE-30997

Panel Producer - 1: Quarterly Test
Inspection Date

N/A

Quarterly Test Date

N/A

Quarter
Test Method

N/A

Contract Laboratory

N

Form 9600-049

CBI

X

Paperwork Reduction Act: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB
Control No. 2070-0185). Responses to this collection of information are mandatory for certain persons, as specified at 40 CFR 770. 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 1,481,525 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.

Panel Producer - 1: Quarterly Test
Inspection Date

01/01/2022

Quarterly Test Date

01/01/2022

Quarter

Q1

Test Method

BS EN ISO 12460-3:2015

Contract Laboratory

N

Panel Producer - 1: Quarterly Test: Product Test - 1
Product Name

test 2

Product Type

test 2

Volume (in Cubic Meters)

50300

Result of Re-Testing

test

Disposition

test

Panel Producer - 1: Quarterly Test
Inspection Date

04/01/2022

Quarterly Test Date

04/01/2022

Quarter

Q2

Test Method

ASTM D5582-14

Contract Laboratory

N

Panel Producer - 1: Quarterly Test: Product Test - 1
Product Name

test 3

Product Type

test 3

Volume (in Cubic Meters)

40000

Result of Re-Testing

test

Disposition

test

Panel Producer - 1: Quarterly Test
Inspection Date

07/01/2022

Quarterly Test Date

07/01/2022

Quarter

Q3

Test Method

DMC (Dynamic Micro Chamber), 2007 User's Manual

Contract Laboratory

N

Panel Producer - 1: Quarterly Test: Product Test - 1
Form 9600-049

Product Name

prod with 1 test

Product Type

type 4

Volume (in Cubic Meters)

8000000

Result of Re-Testing

test

Disposition

N/A

Panel Producer - 1: Quarterly Test
Inspection Date

12/01/2022

Quarterly Test Date

12/01/2022

Quarter

Q4

Test Method

JIS A1460:2015

Contract Laboratory

N

Panel Producer - 1: Quarterly Test: Product Test - 1
Product Name

prod with 1 test

Product Type

type 4

Volume (in Cubic Meters)

600

Result of Re-Testing

test

Disposition

N/A

List of Laboratories
Laboratory Report - 1
Laboratory Name

Test Laboratory N/A

Laboratory Address

1234 Main Street, City, Alabama N/A, UNITED STATES

Primary Contact

William Brigman

Primary Contact Email

[email protected]

Primary Contact Phone No.

8281111234

Secondary Contact

N/A

Secondary Contact Email

N/A

Secondary Contact Phone No.

N/A

Laboratory Accreditation

test

Date of Small Chamber Method
Equivalence

12/31/2022

Laboratory Report - 1: List of Equivalence Data Point Sets

CBI

Equivalence Data Point Set - 1
Large Chamber Result (ppm)

15

Small Chamber Result (ppm)

756

Small Chamber Equivalent to
Large Chamber?

N
CBI

Equivalence Data Point Set - 2
Large Chamber Result (ppm)

1000

Small Chamber Result (ppm)

1000

Small Chamber Equivalent to
Large Chamber?

N
CBI

Equivalence Data Point Set - 3
Large Chamber Result (ppm)

40000

Small Chamber Result (ppm)

30

Small Chamber Equivalent to
Large Chamber?

N
CBI

Equivalence Data Point Set - 4
Large Chamber Result (ppm)

300

Small Chamber Result (ppm)

44

Small Chamber Equivalent to
Large Chamber?

N
CBI

Equivalence Data Point Set - 5
Large Chamber Result (ppm)

400

Small Chamber Result (ppm)

400

Small Chamber Equivalent to
Large Chamber?

N

Inter-Laboratory Comparison
Participated in an InterLaboratory Comparison?

N

List of Non-Conformities
Submitter
Prefix

First Name

Last Name

William

Brigman

Organization Name

CDX Test Org

Suffix

Phone Number

8289191634

Email Address

[email protected]

Mailing Address 1

123 Main St

Mailing Address 2
City

State

Postal Code

Country

Virginia Beach

Virginia

23462

UNITED STATES

General Claim: Submitter Information
Applicable Only to General CBI Claims
A person may assert a claim of confidentiality for the specific chemical identity of a
chemical substance as described in § 711.15(b)(3) of this part only if the identity of that
chemical substance is treated as confidential in the Master Inventory File as of the time the
report is submitted for that chemical substance. Generic chemical identities and accession
numbers may not be claimed as confidential. To assert a claim of confidentiality for the
identity of a reportable chemical substance, you must submit with the report detailed written
answers to the questions from subsection (b) and to the following questions.
Question
G1) 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.

Yes

No

X

CBI

X

Comment: Test

Question
G2) Has your business taken precautions to protect the
confidentiality of the disclosed information? If yes, please
explain and identify the specific measures, including but

Yes

No

CBI

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

X

Comment: Test

Question
G3A) Is any of the information claimed as confidential
required to be publicly disclosed under any other Federal
law? If yes, please explain.

Yes

No

CBI

No

CBI

No

CBI

No

CBI

X

Comment: Test

Question
G3B) 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.

Yes

X

Comment: Test

Question
G3C) 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.

Yes

X

Comment: Test

Question
G4) Is the claim of confidentiality intended to last less than
10 years (see TSCA section 14(e)(1)(B))? If yes, please

Yes

X

indicate the number of years (between 1-10 years) or the
specific date after which the claim is withdrawn.
Comment: Test

Question
G5) 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.
Comment: Test

Yes

X

No

CBI