Sample Notification Form

While there is no required format for a 12(b) export notification, the following sample notification contains all the required elements  

Office of Pollution Prevention and Toxics Environmental Protection Agency 1200 Pennsylvania Avenue NW Washington, DC 20460-0001 

If the export notice is hand delivered, it should be addressed to OPPT Document Control Office (DCO), EPA East, Rm. 6428, Environmental Protection Agency, 1201 Constitution Ave., NW Washington, DC (Attention TSCA Section 12(b) Notice). 

We appreciate your assistance in recording this notification. Should you need additional information or assistance concerning this report, please call the undersigned at telephone number (Insert phone number of company contact). 

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The required notification must be provided at ieast annually In writing. Acceptable forms of notice are, for example, a letter, product labeling, and product literature distributed to customers. If you are required to prepare and distribute a Material Safety Data Sheet (MSDS) for the mixture under the Occupational Safety and Health Act (OSHA) Hazard Communication Standard, your section 313 notification may be attached to the MSDS or the MSDS may be modified to include the required information. (A sample letter and recommended text for inclusion in an MSDS appear on pages E-4 and E-5 of this appendix.)... 

Important A representative of the certified firm may complete this sample form or a similar form when notifying EPA, Consult the ln tivctions for Notifying EPA Commencement of Leed-Based Paint Abatement Activities when preparing abatement notification. Please type or print responses In black or blue ink only. ... 

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