(Recommended format)
TOXIC SUBSTANCES 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 THERE UNDER.”
NEGATIVE CERTIFICATION:
________ “I CERTIFY THAT ALL CHEMICAL IN THIS SHIPMENT
ARE NOT SUBJECT TO TSCA.”
COMPANY NAME: ____________________________________________
COMPANY ADDRESS: _________________________________________
AUTHORIZED SIGNATURE: ____________________________________
TITLE: _______________________________________________________
FEDERAL EXPRESS AWB#: ____________________________________
IF THE CERTIFIER IS UNSURE IF THEIR CHEMICALS FALL UNDER
THE TSCA CATEGORY, CONTACT THE ENVIRONMENTAL
PROTECTION AGENCY: TSCA ASSISTANCE OFFICE WASHINGTON
D.C., U.S. (202) 554-1404 BETWEEN 8:30 AM AND 5:00 PM U.S. EASTERN
STANDARD TIME.