TOXIC SUBSTANCE CONTROL ACT (TSCA)

CERTIFICATION

DATE: ----------------------------

(CHECK ONE SECTION ONLY)

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.”

OR

NEGATIVE CERTIFICATION:

---------------“I CERTIFY THAT ALL CHEMICALS IN THIS SHIPMENT

ARE NOT SUBJECT TO TSCA.”

COMPANY NAME: ----------------------------------------------------------------------

COMPANY ADDRESS: -----------------------------------------------------------------

AUTHORISED NAME: ------------------------------------------------------------------

AUTHORISED SIGNATURE: ----------------------------------------------------------

TITLE: ---------------------------------------------------------------------------------------

FEDERAL EXPRESS AWB#: ---------------------------------------------------------

RETURN TO: ------------------------------------------------------------------------------

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. (202) 554-1404 BETWEEN 8:30 AM AND 5:00 PM EST.