TOXIC SUBSTANCE CONTROL ACT (TSCA)
CERTIFICATION
Date _____________
Manufacturer/Shipper ________________________________________________
Address __________________________________________________________
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Purchase Order No. ________________________________
Positive Certification:
______ I certify that all chemical substances in this shipment comply with all applicable rules or orders under TSCA and that I am not offering a chemical substance for entry in violation of TSCA or any applicable rule or order thereunder."
Chemical ingredients contained in controlled substance: (Attach separate sheet if necessary)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Authorized Name: (type or print) ___________________________________________
Authorized Signature: ___________________________________________________
Title: ________________________________________________________________
If the certifier is unsure if their chemical substance is subject to TSCA compliance, contact the Environmental Protection Agency, TSCA assistance office Washington D.C.
Telephone: 202-554-1404 Fax: 202-554-5603