Attachment A: Nanoscale Materials Stewardship Program Data Form

Notice to Participants:

Participation in and submission of data to the Program is voluntary

EPA is requesting you provide data to the extent it is known or
reasonably ascertainable

Use of this form by Program participants is also voluntary

You do not have to fill out the entire form – you may leave portions
blank when data is not known or reasonably ascertainable

In some instances EPA is requesting that you explain why data is not
available

EPA encourages participants to provide as much data as possible
including why data is not available

You may use the form as a guide to determine which data to report to EPA


Participation in and submission of data to the Program does not imply an
intent to manufacture or import for a commercial purpose

Completion and submission of this form to the Program does not satisfy
any requirement under 40 CFR part 720 to submit a PMN or under 40 CFR
part 721 to submit a Significant New Use Notification



07-09-07 Version. Form Not Approved. 

U.S. ENVIRONMENTAL PROTECTION AGENCY

AGENCY USE ONLY:	Document control number	EPA case number	Date of receipt

When completed 

send this form to

U.S. E.P.A. 

DOCUMENT CONTROL OFFICER (7407M)

1200 PENNSYLVANIA AVE. NW

WASHINGTON, D.C. 20460

ATTN: NANOSCALE MATERIALS STEWARDSHIP PROGRAM

	This form has been developed for the U.S. EPA’s Nanoscale Materials
Stewardship Program.  To ease the burden of reporting, the form is based
on the standard Premanufacture Notice (PMN) form (EPA FORM 7710-25, Rev.
5-95); many of the pages in this form are adapted from those in the PMN
form; irrelevant sections have been removed.  Additional pages seeking
nanoscale materials-specific information are inserted in the most
relevant places.

GENERAL INSTRUCTIONS

As much of this form is adapted from the PMN form, it may be instructive
to read “Instruction Manual for Reporting Under the TSCA §5 New
Chemicals Program” (available from the Toxic Substances Control Act
(TSCA) Information Service, 202-554-1404, or 202-554-5603(fax) or at
http://www.epa.gov/opptintr/newchems/pubs/pmnforms.htm).

Just as in a standard PMN, provide all information requested in this
form to the extent it is known or reasonably ascertainable. 
Particularly as related to the health and environmental effects of the
manufacture, processing, distribution in commerce, use, or disposal of
the substance, all test data in your possession or control and a
description of all other known data should be provided.  Reasonable
estimates or modeling data may be given in the absence of actual data. 
Standard literature citations may be submitted for data in the open
scientific literature.  Complete test data report (written in English),
not summary data, should be submitted, if they do not appear in the open
literature.  Clearly identify whether test data is on the substance, on
an analog, or from models.  

Any answer may be left blank or filled with “N/A,” if the
information is not available, or the question is not applicable (e.g.,
characterization data for tests that were not run, production volume for
materials that are not at the production stage, CAS name and number for
materials not registered with CAS, etc.).  IT IS NOT NECESSARY TO DO
ADDITIONAL TESTING IN ORDER TO COMPLETE THIS FORM.  

Attach additional sheets as needed.  Label each continuation sheet with
the corresponding section heading.  List all attachments including data
and optional information on page 15.  

Only one substance should be submitted per form.

Any information may be claimed as confidential.  To assert a claim on
the form, mark (X) the confidential box next to the information claimed
as confidential.  To assert a claim in an attachment, circle or bracket
the information claimed as confidential.  If information is claimed as
confidential, a sanitized version (including attachments) should be
provided.  For additional instructions on claiming information as
confidential, read the Instructions Manual.  Submission of confidential
information on this form constitutes consent for disclosure of the
information to EPA contractors under the security procedures used in
handling information submitted under TSCA. 

NOTICES 

Participation in and submission of data to the Program is voluntary.  

Use of this form by Program participants is also voluntary. 

Participation in and submission of data to the Program does not imply an
intent to manufacture or import for a commercial purpose.

Completion and submission of this form to the Program does not satisfy
any requirement under 40 CFR part 720 to submit a PMN or under 40 CFR
part 721 to submit a Significant New Use Notice. For information on PMN
submissions, see   HYPERLINK
"http://www.epa.gov/opptintr/newchems/index.htm" 
http://www.epa.gov/opptintr/newchems/index.htm 

TEST DATA  Hazard and exposure test data would be most useful if the
physical/chemical properties of the nanoscale material relevant to
assessing test results are obtained at the initiation of testing. 
Additional relevant information on preparation of the nanoscale material
for administration and storage history of the material between
production and administration will assist in interpretation. When
possible, interpret data in the context of accompanying positive and
negative nanoscale substance control data from the same test system.
Indicate which of the following data are included in this submission:

  FORMCHECKBOX   Physical / Chemical properties

  FORMCHECKBOX   Structure / activity relationships	  FORMCHECKBOX  
Health effects

  FORMCHECKBOX   Exposure ERiskEassessments	  FORMCHECKBOX  
Environmental effects

  FORMCHECKBOX   Environmental fate	  FORMCHECKBOX  

  FORMCHECKBOX  	Test data not in the possession or control of the
submitter

Other

  FORMCHECKBOX  	Mark (x) if any information is claimed as confidential.

	

TIME REQUIRED TO COMPLETE THE FORM

EPA estimates that it will take ???? hours to complete this form,
including time to review instructions, search existing data sources,
gather and maintain the data needed, and complete and review the
collection of information. Please provide an estimate of the amount of
time in work hours it took to complete this form.	Hours:

COMMENTS  

Please provide feedback concerning the Nanoscale Materials Stewardship
Program Data Submission Form.

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

CHECK LIST  

Please verify that the questions in the following general areas were
answered by marking (X) in the boxes.  (Answers may include, for
example, “N/A,” “none,” “not known”).

	  FORMCHECKBOX   Physical and chemical characterization

	  FORMCHECKBOX   Risk management information

STATEMENT

All information provided in this form is accurate as of the date of
submission.

I understand that this is not an actual PMN, and as such, does not
satisfy any requirement under 40 CFR part 720 to submit a PMN.

	Confidential

Signature and title of Authorized Official (Original Signature Required)

 	Date

	



Signature of agent  - (if applicable)

	Date

	





Part I -- GENERAL INFORMATION

Section A -- SUBMITTER IDENTIFICATION	Confi-

Mark () the “Confidential” box next to any subsection you claim as
confidential	dential

1a.	Person Submitting 

       (in U.S.)	Name of authorized official

   FORMTEXT   	Position

  FORMTEXT    	

  FORMTEXT   

	Company

 

  FORMTEXT   



Mailing address (number and street)

   FORMTEXT   



City, State, ZIP Code

   FORMTEXT   



 b.	Agent (if applicable)	Name of authorized official

  FORMTEXT   	Position

  FORMTEXT   	

  FORMTEXT   

	Company

  FORMTEXT   



Mailing address (number and street)

c.	If you are submitting this as part of a joint submission, mark (X)
this box.

	  FORMCHECKBOX  

	Joint Submitter (if applicable)	Name of authorized official

  FORMTEXT   	Position

  FORMTEXT   	

  FORMTEXT   

	Company

  FORMTEXT   



Mailing address (number and street)

  FORMTEXT   



City, State, ZIP Code	Telephone	Area Code	Number



  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

	2.	Technical Contact (in U.S.)	Name of authorized official

   FORMTEXT   	Position

  FORMTEXT    	

  FORMTEXT   

	Company

   FORMTEXT   



Mailing address (number and street)

   FORMTEXT   



City, State, ZIP Code	Telephone	Area Code	Number



   FORMTEXT   

  FORMTEXT   	  FORMTEXT   





	



Part I -- GENERAL INFORMATION -- Continued

	Section B -- CHEMICAL IDENTITY INFORMATION: **

	Mark (X) the “Confidential” box next to any item you claim as
confidential

	Complete either item 1 (Class 1 or 2 substances) or 2 (Polymers) as
appropriate.  Complete all other items.

	If another person will submit chemical identity information for you
(for either Item 1 or 2), mark (X) the box at the right.

	Identify the name, company, and address of that person in a
continuation sheet.	  FORMCHECKBOX  	Confi-

dential

1.	Class 1 or 2 chemical substances (for definitions of class 1 and
class 2 substances, see the Instructions Manual) **

	a.	Class of substance - Mark (X)	1	  FORMCHECKBOX  	Class 1	or	2	 
FORMCHECKBOX  	Class  2

		b.	Chemical name (Currently correct Chemical Abstracts (CA) Name that
is consistent with TSCA Inventory listings for similar substances.  **

		 



		c.	Please identify which method you used to develop or obtain the
specified chemical identity information: (check one).

		  FORMCHECKBOX  	Method 1 (CAS Inventory Expert Service 	 
FORMCHECKBOX  	Method 2 (Other Source)

		d.	Molecular formula and CAS Registry Number (if a number already
exists for the substance)  **

	  FORMTEXT   	CAS#

		  FORMTEXT   

		e.	For a class 1 substance, provide a complete and correct chemical
structure diagram.  For a class 2 substance - (1) List the immediate
precursor substances with their respective CAS Registry Numbers.  (2)
Describe the nature of the reaction or process.  (3) Indicate the range
of composition and the typical composition (where appropriate).  (4)
Provide a correct representative or partial chemical structure diagram,
as complete as can be known, if one can be reasonably ascertained.  **

	

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



Part I -- GENERAL INFORMATION -- Continued

Section B -- CHEMICAL IDENTITY INFORMATION -- Continued

2.	Polymers (For a definition of polymer, see the Instructions Manual.)
Confi-

dential

	a.	Indicate the number-average weight of the lowest molecular weight
composition of the polymer you intend to manufacture.

		Indicate maximum weight percent of low molecular weight species (not
including residual monomers, reactants, or solvents) below 500 and below
1,000 absolute molecular weight of that composition.	



		Describe the methods of measurement or the basis for your estimates:
GPC	  FORMCHECKBOX  		Other      FORMCHECKBOX  :	(Specify)		  FORMTEXT  
		

		i)	lowest number average molecular weight:		  FORMTEXT   	

		ii)	maximum weight % below 500 molecular weight:		  FORMTEXT   	

		iii)	maximum weight % below 1000 molecular weight:		  FORMTEXT   	



  FORMCHECKBOX  		Mark (X) this box if you attach a continuation sheet.

	b.	Make separate confidentiality claims for monomer or other reactant
identity, composition information, and residual information.  Mark (X)
the “Confidential” box next to any item you claim as confidential

		(1)	-	Provide the specific chemical name and CAS Registry Number (if a
number exists) of each monomer or other reactant used in the manufacture
of the polymer.

		(2)	-	Mark (X) this column if entry in column (1) is confidential.

		(3)	-	Indicate the typical weight percent of each monomer or other
reactant in the polymer.

		(4)	-	Mark (X) the identity column if you want a monomer or other
reactant used at two weight percent or less to be listed as part of the
polymer description on the TSCA Chemical Substance Inventory.

		(5)	-	Mark (X) this column if entries in columns (3) and (4) are
confidential.

		(6)	-	Indicate the maximum weight percent of each monomer or other
reactant that may be present as a residual in the polymer as
manufactured for commercial purposes.

		(7)	-	Mark (X) this column if entry in column (6) is confidential.

Monomer or other reactant and CAS Registry Number

(1)	Confi-

dential

(2)	Typical

composition

(3)	Identity

Mark (X) (4)	Confi-

dential

(5)	Maximum

residual

(6)	Confi-dential

(7)

  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMTEXT   

  FORMTEXT    %

	  FORMTEXT    %

	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

		c.	Please identify which method you used to develop or obtain the
specified chemical identity information (check one).   

	  FORMCHECKBOX  	Method 1	(CAS Inventory Expert Service)	  FORMCHECKBOX
 	Method 2 (other source)

					

		d.	The currently correct Chemical Abstracts (CA) name for the polymer
that is consistent with TSCA Inventory listings for similar polymers. **

	



Part I -- GENERAL INFORMATION -- Continued	

Section B -- CHEMICAL IDENTITY INFORMATION -- Continued

3.	Impurities

	(a)	-	Identify each impurity that may be reasonably anticipated to be
present in the chemical substance as manufactured for commercial
purpose.  Provide the CAS Registry Number if available.  If  there are
unidentified impurities, enter “unidentified.”

	(b)	-	Estimate the maximum weight % of each impurity.  If there are
unidentified impurities, estimate their total weight %.

Impurity and CAS Registry Number

(a)	Maximum

percent

(b)	Confi-

dential

  FORMTEXT   	  FORMTEXT    %

	  FORMTEXT   	  FORMTEXT    %

	  FORMTEXT   	  FORMTEXT    %

	  FORMTEXT   	  FORMTEXT    %

	  FORMTEXT   	  FORMTEXT    %

	  FORMTEXT   	  FORMTEXT    %

	  FORMTEXT   	  FORMTEXT    %

	  FORMCHECKBOX  		Mark  (X) this box if you attach a continuation
sheet.

	4.	Synonyms - Enter any chemical synonyms for the chemical identified
in subsection 1 or 2.	Confi-

dential

  FORMTEXT   

	  FORMCHECKBOX  		Mark  (X) this box if you attach a continuation
sheet.

	5.	Trade identification - List trade names for the chemical substance
identified in subsection 1 or 2.

	

  FORMTEXT   

	  FORMCHECKBOX  		Mark  (X) this box if you attach a continuation
sheet.

	6.	Generic chemical name -	If you claim chemical identify as
confidential, provide a generic name for your substance that reveals the
specific chemical identity of the chemical substance to the maximum
extent possible.  Refer to the TSCA Chemical Substance Inventory, 1985
Edition, Appendix B for guidance on developing generic names.

			  FORMTEXT   

  FORMCHECKBOX  		Mark  (X) this box if you attach a continuation sheet.

7.	Byproducts -	Describe any byproducts resulting from the manufacture,
processing, use, or disposal of the chemical substance.  Provide the CAS
Registry Number if available.

Byproduct

(1)	CAS Registry Number

(2)	Confi-



Part I -- GENERAL INFORMATION -- Continued

Section C -- PRODUCTION, IMPORT, AND USE INFORMATION:

			Mark (X) the “Confidential” box next to any item you claim as
confidential.

1.	Production volume -- Estimate the maximum production volume during
the first 12 months of production.  Also estimate the maximum production
volume for any consecutive 12-month period during the first three years
of production.  Estimates should be on 100% chemical substance basis.  

Maximum first 12-month production (kg/yr)

(100% chemical substance basis)	Maximum 12-month production (kg/yr)

(100% chemical substance basis)	Confi-dential

	

  FORMTEXT   	

  FORMTEXT   	

  FORMTEXT   

	2.	Use Information -- Make separate confidentiality claims for the
description of the category of use, the percent of production volume
devoted to each category, the formulation of  the substance, and other
use information.  Mark (X) the “Confidential” Box next to any item
you claim as confidential.

	a.	(1) --	Describe each intended category of use of the chemical
substance by function and application..

		(2) --	Mark (X) this column if entry column (1) is confidential
business information (CBI).

		(3) --	Estimate the percent of total production for the first three
years devoted to each category of use.

		(4) --	Mark (X) this column if entry in column (4) is confidential
business information (CBI).

		(5) --	Estimate the percent of the substance as formulated in
mixtures, suspensions, emulsions, solutions, or gels as manufactured for
commercial purposes at sites under your control associated with each
category of use.

		(6) --	Mark (X) this column if entry in column (6) is confidential
business information (CBI).

		(7) --	Indicate % of product volume expected for the listed “use”
sectors.  Mark more than one box if appropriate. 

		(8) --	Mark (X) this column if entry(ies) in column (8) is (are)
confidential business information (CBI).

Category of use (1)	CBI

Produc-tion %	CBI	% in

Form-	CBI	% of substance expected per use

(7)	CBI

(by function and application i.e. a dispersive dye for finishing
polyester fibers)	

(2)



(3)	

(4)	ulation

(5)	

(6)	Site-

limited	Con-*

sumer	Indus-trial	Com-mercial



(8)

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   

  FORMTEXT    %	  FORMTEXT   	  FORMTEXT    %	  FORMTEXT   	  FORMTEXT  
	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

*	If you have identified a “consumer” use, please provide on a
continuation sheet a detailed description of the use(s) of this chemical
substance in consumer products.  In addition include estimates of the
concentration of the chemical substance as expected in consumer products
and describe the chemical reactions by which this substance loses its
identity in the consumer product.

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

	b.	Generic

		use description	If you claim any category of use description in
subsection 2a as confidential, enter a generic description of that
category.  Read the Instructions Manual for examples of generic use
descriptions.

			  FORMTEXT   



	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

3.	Hazard Information -- Include a copy of reasonable facsimile of any
hazard warning statement, label, material safety data sheet, or other
information which will be provided to any person who is reasonably
likely to be exposed to this substance regarding protective equipment or
practices for the safe handing, transport, use, or disposal of the
substance.  List in part III hazard information you include.

	



Part I -- GENERAL INFORMATION – Continued

Section C –-Continued

Mark (X) the “CBI” box next to any item you claim as confidential.
CBI

4. State of manufacture or importation

Please specify:

	a. Substance is at what stage of manufacture (importation)? 

	  FORMCHECKBOX   currently manufactured 	  FORMCHECKBOX   will be
manufactured	  FORMCHECKBOX   no plan to manufacture				  FORMCHECKBOX  
not known	  FORMCHECKBOX  

	b. First/planned date of manufacture/import:

	  FORMCHECKBOX  

5. State of commercial availability

Please specify:

	a. Substance is at what stage of commercial availability? 

	  FORMCHECKBOX   currently available   	  FORMCHECKBOX   will be made
available    	  FORMCHECKBOX   no plan to make commercially available	 
FORMCHECKBOX   not known	  FORMCHECKBOX  

	b. First/planned date of commercial availability:

	  FORMCHECKBOX  

6. Nanoscale properties.  Briefly describe any unique or enhanced
properties that arise from the nanoscale features of the material,
particularly in contrast to any non-nanoscale varieties that exist. 	 
FORMCHECKBOX  



  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

7. Briefly explain why this material is designed and/or produced to be a
nanoscale material.	  FORMCHECKBOX  



  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE

Section A – INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER	Mark (X) the
“Confidential” box next to any item you claim as confidential

Complete section A for each type of manufacture, processing, or use
operation involving the chemical substance at industrial sites you
control.  See instructions manual

	1.	Operation description

		a.	Identity -- Enter the identity of the site at which the operation
will occur.	Confi-

dential

	Name

   FORMTEXT   	  FORMTEXT   

	Site address (number and street)

  FORMTEXT   



City, County, State, ZIP code

	If the same operation will occur at more than one site, enter the
number of sites.  Identify the additional sites on a continuation sheet,
and if any of the sites have significantly different production rates or
operations, include all the information requested in this section for
those sites as attachments.

  FORMTEXT   	  FORMTEXT   

		  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

			b.	Type --

			Mark (X)	

  FORMCHECKBOX  	Manufacturing	

  FORMCHECKBOX  	Processing	

  FORMCHECKBOX  	Use

		c.	Amount and Duration -- Complete 1 or 2 as appropriate





1.	Batch	Maximum kg/batch (100%  chemical substance)

   FORMTEXT    	Hours/batch

  FORMTEXT    	Batches/year

  FORMTEXT    





2.	Continuous	Maximum kg/day (100%  chemical substance)

  FORMTEXT     	Hours/day

  FORMTEXT    	Days/year

  FORMTEXT    

	d.	Process description	



	(1)	Diagram the major unit operation steps and chemical conversions. 
Include interim storage and transport containers (specify- e.g. 5 gallon
pails, 55 gallon drum, rail car, tank truck, etc.).

	(2)	Provide the identity, the approximate weight (by kg/day or kg/batch
on a 100%  chemical substance basis), and entry point of all starting
materials and feedstocks (including reactants, solvents, catalysts,
etc.), and of all products, recycle streams, and wastes.  Include
cleaning chemicals (note frequency if not used daily or per batch.).

	(3)	Identify by number the points of release, including small or
intermittent releases, to the environment of the chemical substance.  If
releasing to two media at the same step, assign a second release number
for the second medium.





Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued

Section A – INDUSTRIAL SITES CONTROLLED BY THE SUBMITTER – Continued

2.	Occupational Exposure -- Make separate confidentiality claims for 
the description of worker activity, physical form of the chemical
substance, number of workers exposed, and duration of activity.  Mark
(X) the “Confidential” box next to any item you claim as
confidential.

	(1) --	Describe the activities (i.e. bag dumping, tote filling,
unloading drums, sampling, cleaning, etc.) in which workers may be
exposed to the substance.

	(2) --	Mark (X) this column if entry in column (1) is confidential
business information (CBI).

	(3) --	Describe any protective equipment and engineering controls used
to protect workers.

	(4) --	Indicate the physical form(s) of the chemical substance (e.g.,
solid: crystal, granule, powder, or dust) and %  chemical substance (if
part of a mixture) at the time of exposure.

	(5) --	Mark (X) this column if entry in column (4) is confidential
business information (CBI).

	(6) --	Estimate the maximum number of workers involved in each activity
for all sites combined.

	(7) --	Mark (X) this column if entry in column (6) is confidential
business information (CBI).

	(8) 	and (9) -- Estimate the maximum duration of the activity  for any
worker in hours per day and days per year.

	(10)	-- Mark (X) this column if entries in columns (8) and (9) are
confidential business information (CBI).

Worker activity	CBI	Protective Equipment/

Physical forms(s)

CBI	# of	CBI	Maximum	duration	CBI

(i.e., bag dumping, filling drums)

(1)	

(2)	Engineering Controls

(3)

and %  substance

(4)



(5)	Workers Exposed

(6)	

(7)	Hrs/day

(8)	Days/yr

(9)	

(10)

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

3.	Environmental Release and Disposal -- Make separate confidentiality
claims for the release number and the amount of the chemical substance
released and other release and disposal information.  Mark (X) the
“Confidential” box next to each item you claim as confidential.

	(1) --	Enter the number of each release point identified in the process
description, part II, section A, subsection 1d(3).

	(2) --	Estimate the amount of the substance released (a) directly to
the environment or (b) into control technology (in kg/day or kg/batch).

	(3) --	Mark (X) this column if entries in columns (1) and (2) are
confidential business information (CBI).

	(4) --	Identify the media (stack air, fugitive air (optional-see
Instruction Manual), surface water, on-site or off-site land or
incineration, POTW, or other (specify)) to which the substance will be
released from that release point.

	(5) --	a.  Describe control technology, if any, and control efficiency
that will be used to limit the release of the substance to the
environment.  For releases disposed of on land, characterize the
disposal method and state whether it is approved for disposal of RCRA
hazardous waste.  On a continuation sheet, for each site describe any
additional disposal methods that will be used and whether the waste is
subject to secondary or tertiary on-site treatment.  b. Estimate the
amount released to the environment after control technology (in kg/day).

	(6) --	Mark (X) this column if entries in columns (4) and (5) are
confidential business information (CBI).

	(7) --	Identify the destination(s) of releases to water.  Please supply
NPDES (National Pollutant Discharge Elimination System) numbers for
direct discharges or NPDES numbers of the POTW (Publicly Owned Treatment
Works).  Mark (X) if the POTW name or NPDES # is confidential business
information (CBI).

Release

Number	Amount of substance released	CBI	Media of

release	Control technology and efficiency (you may wish to optionally
attach efficiency data)	CBI

(1)	(2a)	(2b)	

(3)	e.g. stack air

(4)	

(5a)



(5b)	

destination(s) of releases to water.

	

  FORMTEXT   	  FORMTEXT   		waterway

  FORMTEXT   	

  FORMTEXT   	

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued

Section B – INDUSTRIAL SITES CONTROLLED BY OTHERS

Complete section B for typical processing or use operations involving
the chemical substance at sites you do not control.  See the
Instructions Manual. Complete a separate section B for each type of
processing, or use operation involving the chemical substance.  If the
same operation is performed at more than one site describe the typical
operation common to these sites.  Identify additional sites on a
continuation sheet.

1.	Operation Description -- To claim information in this section as
confidential, circle or bracket the specific information that you claim
as confidential.

	(1) -- Diagram the major unit operation steps and chemical conversions,
including interim storage and transport containers (specify - e.g. 5
gallon pails, 55 gallon drums, rail cars, tank trucks, etc).  On the
diagram, identify by letter and briefly describe each worker activity. 
(2) -- Provide the identity, the approximate weight (by kg/day or
kg/batch, on a 100%  chemical substance basis), and entry point of all
feedstocks (including reactants, solvents and catalysts, etc) and all
products, recycle streams, and wastes.  Include cleaning chemicals (note
frequency if not used daily or per batch).  (3) -- Identify by number
the points of release, including small or intermittent releases, to the
environment of the chemical substance.  (4) Please enter the # of sites
(remember to identify the locations of these sites on a continuation
sheet):

	  FORMTEXT   			

# of sites				

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

2.	Worker Exposure/Environmental Release

	(1) --	From the diagram above, provide the letter for each worker
activity.  Complete 2-8 for each worker activity described.

	(2) --	Estimate the number of workers exposed for all sites combined.

	(4) --	Estimate the typical duration of exposure per worker in (a)
hours per day and (b) days per year.

	(6) --	Describe physical form of exposure and %  chemical substance (if
in mixture), and any protective equipment and engineering controls, if
any, used to protect workers.

	(7) --	Estimate the percent of the substance as formulated when
packaged or used as a final product.

	(9) --	From the process diagram above, enter the number of each release
point.  Complete 9-13 for each release point identified.

	(10) 	--     Estimate the amount of the substance released (a) directly
to the environment or (b) into control technology to the environment (in
kg/day or kg/batch).

	(12)	--     Describe media of release i.e. stack air, fugitive air
(optional-see Instructions Manual), surface water, on-site or off-site
land or incineration, POTW, or other (specify) and control technology,
if any, that will be used to limit the release of the substance to the
environment. 

	(14)	--     Identify byproducts which may result from the operation.

	(3), (5), (8), (11), (13) and (15) -- Mark (X) this column if any of
the proceeding entries are confidential business information (CBI).

Letter

of

Act-ivity	# of

Workers

Exposed	CBI	Duration 

of

Exposure	CBI	Protective Equip. /

Engineering Controls/

Physical Form and %

substance	% in

Form-

ulation	CBI	Release

Number	Amount of

Substance

Released	CBI	Media of Release

& Control

Technology	CBI

(1)	(2)	(3)	(4a)	(4b)	(5)	(6)	(7)	(8)	(9)	(10a)	(10b)	(11)	(12)	(13)

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	 
FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   	  FORMTEXT   

(14) -- Byproducts:

  FORMTEXT   	(15)



Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued

Section A / B, Subsection 2. Occupational Exposure – Continued.  b.
Details of protective equipment / engineering controls.   

(Use this form both for sites controlled by submitter and by others. 
Make copies as necessary.)

Please provide the following information:

	(1) –The worker activities listed in Section A.2 or B.1 for which
protective equipment/engineering controls are in use.

	(2) – A brief description of the rationale for selecting the
protective equipment/engineering controls, including internal exposure 

               control limits, data and the methods used to generate the
data that informed the decision.

	(3) – A brief description of the cleaning, reuse, and/or disposal of
the protective equipment

	(4) – A brief description of any data (personal and/or area), units
(e.g., mass conc., surface area, or particle number conc.) and

               any exposure monitoring methods used.

Mark (X) in the “CBI” column next to any item you claim as
confidential.	CBI

(1) Worker activity / Protective equipment / Engineering Control	 
FORMCHECKBOX  

	 (2) Rationale for selecting equipment / controls, associated internal
exposure control limit / data / methods

	  FORMCHECKBOX  



	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



(3) Cleaning, reuse, and/or disposal of protective equipment

	  FORMCHECKBOX  



	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



(4) Exposure monitoring data (personal and/ or area), units (e.g., mass
conc., surface area, or particle number conc.), and methods used

	  FORMCHECKBOX  



	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

Section A.3 / Section B, subsection 2. Environmental Release and
Disposal – Continued.  Details of control technology.

(Use this form both for sites controlled by submitter and by others.
Make copies as necessary)

To assist EPA in gaining a better understanding of the need for and the
types of control technology used at the release points in the
manufacture and handling of engineered nanoscale materials, please
provide the following information for each release point for which
control technology is used:

	(1) – The Release Number, as identified in the process description,
part II, section A, subsection 1d(3) (page 8).

	(2) – A brief description of the rationale for selecting the control
technology.

	(3) – Data and measurement methods of waste treatment efficiency
studies.

Release

Number (1)	Mark (X) in the “CBI” column next to any item you claim
as confidential.	CBI

	(2) Rationale for selecting control technology

	  FORMCHECKBOX  







	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



(3) Data and measurement methods of waste treatment or purification
studies

	  FORMCHECKBOX  



	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



Part II-- HUMAN EXPOSURE AND ENVIRONMENTAL RELEASE -- Continued

Section C – Lifecycle

Mark (X) the “CBI” box next to any item you claim as confidential.
CBI

1. In addition to the information already given, provide a brief
overview of the lifecycle of the material, including all workplaces that
manufacture, process, or use the material, methods of packaging and
transporting the material, all expected general population,
environmental, and consumer uses, and the expected manufacturing and
processing methods of the material or any consumer products 	 
FORMCHECKBOX  

containing the material. If not included in Sections A or B above,
include a description of the end of life disposal or disposition of
products containing the nanoscale material.



  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

Section D – Misc. Health, Exposure, Hazard Information

Mark (X) the “CBI” box next to any item you claim as confidential.
CBI

1. Describe any training, hazard communication (e.g. MSDS), etc.
specific to the nanoscale material that is provided to workers.	 
FORMCHECKBOX  





  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

2. Estimate the total number of individuals—other than previously
described workers—(e.g. general public, consumers) who may be exposed
to the material and the duration of the exposure.	  FORMCHECKBOX  





  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

3. Describe any other procedure, equipment, etc. being used to mitigate
exposure to the material.	  FORMCHECKBOX  





  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

4. Describe product labeling and any customer training specific to the
nanoscale material.	  FORMCHECKBOX  





  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.

5. Describe other risk management practices specific to the nanoscale
material.	  FORMCHECKBOX  





  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



OPTIONAL POLLUTION PREVENTION INFORMATION

To claim information in this section as confidential circle or bracket
the specific information that you claim as confidential.

In this section you may provide information not reported elsewhere in
this form regarding your efforts to reduce or minimize potential risks
associated with activities surrounding manufacturing, processing, use
and disposal of the substance.  Please include new information pertinent
to pollution prevention, including source reduction, recycling
activities and safer processes or products available due to the chemical
substance.  Source reduction includes the reduction in the amount or
toxicity of chemical wastes by technological modification, process and
procedure modification, product reformulation, raw materials
substitution, and/or inventory control.  Recycling refers to the
reclamation of useful chemical components from wastes that would
otherwise be treated or released as air emissions or water discharges,
or land disposal.  Descriptions of pollution prevention, source
reduction and recycling should emphasize potential risk reduction
subsequent to compliance with existing regulatory requirements and can
be either quantitative or qualitative.  EPA is interested in the
information to assess overall net reductions in toxicity or
environmental releases and exposures, not the shifting of risks to other
environmental media or non-environmental areas (e.g., occupational or
consumer exposure).  In addition, information on the relative cost or
performance characteristics of the substance to potential alternatives
may be provided.

  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



Part III -- LIST OF ATTACHMENTS



Attach continuation sheets for sections of the form and test data and
other data (including physical/chemical properties and
structure/activity information), and optional information after this
page.  Clearly identify the attachment and the section of the form to
which it relates, if appropriate.  Number consecutively the pages of the
attachments.  In the column below, enter the inclusive page numbers of
each attachment.

Mark (X) the “Confidential” box next to any attachment name you
claim as confidential.  Read the Instructions Manual for guidance on how
to claim any information in an attachment as confidential. Include with
the sanitized copy of the form a sanitized version of any attachment in
which you claim information as confidential.

	Attachment name	Attachment

page number(s)	Confi-dential





PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET **

To assist EPA’s review of physical and chemical properties data,
please complete the following worksheet for data you provide and include
it in the form.  Identify the property measured, the page of the form on
which the property appears, the value of the property, the units in
which the property is measured (as necessary), and whether or not the
property is claimed as confidential.  The physical state of the neat
substance should be provided.  These measured properties should be for
the neat (100% pure) chemical substance.  Properties that are measured
for mixtures or formulations should be so noted (% substance in __).  

Property

(a)	Mark (X) if provided	Page number (b)	Value

(c)	Measured or Estimate

(M or E)	Confi-dential Mark (X)

(d)

	

	Physical state of neat substance

	

		 (s)		 (l)		 (g)





	Vapor pressure

		@ Temperature				°C

	

						Torr		

	

	Density/relative density

	

						g/cm3

	



	Solubility

		@	Temperature 			°C

		Solvent				

	

						g/L





	Solubility in water @ Temperature			°C

	

						g/L			

	

	Melting temperature

	

						°C			

	

	Boiling / sublimation temperature@		torr pressure

	

						°C





	Spectra





	

	Dissociation constant





	







	

	Octanol / water partition coefficient





	

	Henry’s Law constant





	

	Volatilization from water





	

	Volatilization from soil





	

	pH	@ concentration				





	

	Flammability





	

	Explodability





	

	Adsorption / coefficient





	







	







	



PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET II

To assist EPA in understanding the types of characterization data
typically available for engineered nanoscale materials and the cost of
obtaining that data, for each of the physical and chemical properties
submitted on page 16, provide: the approximate cost of obtaining data,
the method used to obtain the data, and, if a particular piece of data
was not collected, a brief reason why.  If non-standard methods were
used in the collection of data, briefly describe them.

Property	Mark (X) if provided	Method used	Confi-dential Mark (X)	Approx.
Cost	Confi-dential Mark (X)

	Physical state of neat substance



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Vapor pressure





  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Density/relative density



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Solubility in solvent	

				



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Solubility in water



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Melting temperature



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Boiling / sublimation temperature



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Spectra



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Dissociation constant



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

	

PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET II – Continued

Property	Mark (X) if provided	Method used	Confi-dential Mark (X)	Approx.
Cost	Confi-dential Mark (X)

	Octanol / water partition coefficient



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Henry’s Law constant



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Volatilization from water



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Volatilization from soil



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		pH



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Flammability



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Explodability



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Adsorption / coefficient



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

	



PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET III – Nanoscale Materials
Specific Data

Please provide the additional chemical and physical characterization
data listed below.  Additional pages may be attached to provide more
information.

Property	Mark (X)  

if provided	Mark (X) if page attached	Value	Measured / Estimated

(M or E)	CBI

 Mark (X)

General Characteristics

	Crystal structure



	

		Agglomeration state



		

Particle Characteristics

Particle size distribution 

	Provide graph with percentage of particles in each diameter class.  For
elongated particles, provide length distribution graph showing the
percentage of particles in each length class.



		Mean particle size (diameter and/or length)

	nm



			Standard deviation from mean





			Largest particle size (diameter and/or length)

	nm



		Smallest particle size (diameter and/or length)

	nm



		Aspect ratio





			Average aerodynamic diameter

	nm



	Average particle mass

	g



	Particle shape





	Surface Characteristics

	Surface area

	m2/g



	Average particle surface area

	m2



	Surface charge (Zeta potential)

	mV



	Porosity





		Surface chemical composition





		Surface / volume ratio





	Other

	Other



















	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET III cont– Nanoscale
Materials Specific Data

Please provide the additional chemical and physical characterization
data listed below.  Additional pages may be attached to provide more
information.

Property	Mark (X)  

if provided	Mark (X) if page attached	Value	Measured / Estimated

(M or E)	CBI

 Mark (X)

Fate and Transport

	Diffusion rate





		Gravitational settling rate





		Sorption rate





		Deposition rate





		Wet and dry transport





		Biodegradation rate





		Bioaccumulation





	Biotransformation





		Influence of redox/photochemical reaction 





	Other

	Other





	  FORMCHECKBOX  	Mark (X) this box if you attach a continuation sheet.



		PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET IV

To assist EPA in understanding the types of characterization data
typically available for engineered nanoscale materials and the cost of
obtaining that data, for each of the physical and chemical properties
submitted on page 19, provide: the approximate cost of obtaining data,
the method used to obtain the data, and, if a particular piece of data
was not collected, a brief reason why.  If non-standard methods were
used in the collection of data, briefly describe them.

Property	Mark (X) if provided	Method used	Confi-dential Mark (X)	Approx.
Cost	Confi-dential Mark (X)

	Crystal structure



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Agglomeration state



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Particle size distribution





  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Mean particle size and standard deviation 



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Largest particle size



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Smallest particle size



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Aspect ratio



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Average aerodynamic diameter 





  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Average particle mass



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

	

		PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET IV continued

Property	Mark (X) if provided	Method used	Confi-dential Mark (X)	Approx.
Cost	Confi-dential Mark (X)

	Particle shape	



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Surface area





  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Average particle surface area



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Surface charge



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Porosity



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Surface chemical composition



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Surface / volume ratio



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Diffusion rate



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Gravitational settling rate



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

	

		PHYSICAL AND CHEMICAL PROPERTIES WORKSHEET IV continued

Property	Mark (X) if provided	Method used	Confi-dential Mark (X)	Approx.
Cost	Confi-dential Mark (X)

	Sorption rate





  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Deposition rate



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Wet and dry transport



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Biodegradation rate



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Bioaccumulation



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Biotransformation



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Influence of redox / photochemical reaction



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Other



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

		Other



  FORMCHECKBOX   Mark (X) if description of method attached



			If not provided, why?: 	  FORMCHECKBOX   Not applicable     
FORMCHECKBOX   Too expensive      FORMCHECKBOX   Too much test material
required      FORMCHECKBOX   No known method

		  FORMCHECKBOX   Other (specify):

	

** Notes

Part I

Section B:  It is recognized that systematic nomenclature has not been
fully developed for nanoscale materials, therefore it is not necessary
to provide the “correct Chemical Abstract name” nor the “CAS
Registry Number,” if it does not exist.  Please fill out these
sections to the best of your ability in light of the limitations.  

B.1.a:  It is noted that a nanoscale material may or may not be
accurately described as a Class 1 or Class 2 substance.  If the choice
is not obvious, this section may be left blank.  In addition, a brief
explanation may be given for why a particularly classification is or is
not appropriate.

B.1.b / B.2.d:  If a Chemical Abstracts Name is not available, please
use a name that is most in agreement with CA nomenclature.

B.1.d may be read as: 

d. Molecular formula (including molecular shape / physical form) and CAS
Registry Number (if a number already exists for the substance).

B.1.e:  For the nanoscale material, please provide the information
requested for Class 2 substances, regardless of whether the material is
Class 1 or Class 2 or cannot be determined. 

B.2.e may be read as:

"Provide a correct representative or partial chemical structure diagram,
as complete as can be known, if one can be reasonably ascertained. 
Alternatively, if applicable, provide a correct representative structure
for the polymer as part of a composite."

[Note: the components of a composite are separate chemical identities. 
For example in a composite of starch molecules between layers of clay
treated with surfactants, the starch, clay, and surfactants might be on
the TSCA Inventory, but since the interactions between the components
are weak electrical interactions, there is no chemical substance.]

Physical and Chemical Properties Worksheet

It is noted that, for nanoscale materials, protocols and methods may not
exist or be standardized for measurement of the physical and chemical
properties listed in this worksheet.

Based on EPA FORM 7710-25 (Rev. 5-95).  						Page   PAGE  1  of  
NUMPAGES  25 					Draft version—NOT AN OFFICIAL FORM

ATTACHMENT

PAGE    PAGE  14 

Based on EPA FORM 7710-25 (Rev. 5-95).  						Page   PAGE  25  of  
NUMPAGES  25 		                      

ATTACHMENT

PAGE    PAGE  14 

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 11

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 3

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 5

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 6

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 4

Identical to PMN Form EPA 7710-25 (Rev. 5-95) Page 3

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 8

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 9

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 7

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 10

Page 10-NMSP-2

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 13

Based on PMN Form EPA 7710-25 (Rev. 5-95) Page 12

