Toxic Substance Control Act (Tsca) Certification
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1Toxic Substance Control Act (TSCA) Certification
Date:
Waybill or reference number:
Check only one
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:
Certifier name:
Certifier title:
Certifier phone number:
Certifier email address:
Certifier signature:
Product description
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If the certifier is unsure if their chemical substance is subject to TSCA compliance, contact the Environmental
Protection Agency, TSCA Assistance Office at 1.202.554.1404 between 8:30 a.m. and 5:00 p.m.
Rev 1/17
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