 
     A.  	Basic Formulation
             Alternative Formulation
       Alt. # 


   Office of Pesticide Programs (7505C) - Confidential Statement of Formula
1. Name and Address of Applicant/Registrant (Include ZIP Code)
 
 
 
 
2. Name and Address of Producer (Include ZIP Code)
 
 Establishment No.
3. Product Name
 
4. Registration No./File Symbol
5. EPA Product Mgr/Team No.
6. Viscosity/Contents Under Pressure
                                        

7. Pounds/Gal or Bulk Density
                                         
8. pH
                                         
9. Flash Point/Flame Extension
                                        
                                 EPA USE ONLY
10. Components in Formulation (List as actually introduced in the formulation. Give commonly accepted chemical name, trade name, and CAS number.)
11. Supplier Name & Address


12. EPA Reg No./File
Symbol
13. Each Component in Formulation
14. Certified Limits (% by Weight)

15. Purpose in Formulation





a. Amount
b. % by Weight (% Nominal)
a. Upper Limit
b. Lower Limit




















16. Typed Name of Approving Official
17. Total Weight
                                     100%

18. Signature of Approving Official
19. Title
20. Phone No. (Include Area Code)
21. Date
Appendix
Confidential Business Information: Does not contain National Security Information (E.O. 12065)                                        OMB No. XXXX-XXXX Approval expires X-XX-X Page 1 of 1



