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Form Approved. OMB Nos. 2070-0060; 2070-0057; 2070-0107

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

120 0 Pe nn sylv ania Avenue, N.W .

WASHING TON , D.C. 20460

Paperwork Reduction Act Notice: The public reporting burden for this collection of information is estimated to average 0.25 hours per response

for registration activities and 0.25 hours per response for reregistration and special review activities, including time for reading the instructions and

completing the necessary forms.

Send com

ments regarding the burden estimate or any other aspect of this collection of information, including

suggestions for reducing the burden to: Director, Collection Strategies Division (2822T), U.S. Environmental Protection Agency, 1200

Pennsylvania Avenue, N.W., Washington, DC 20460.

Do not send the form to this address.

SELF-CERTIFICATION STATEMENT FOR THE

PHYSICAL/CHEMICAL PROPERTIES (PR NOTICE 98-1)

Product Name:

Pesticide X

Reg. No./File Symbol No.

(if known) or Company No.

xxxx-xxx

SELF-CERTIFICATION STATEMENT :

I certify that the reported information on the “Summary Form” represents a true and accurate record of

Company A

the test results of studies generated or owned by (Company Name):

and that the values of the properties reported are reliable.

I further certify that such data were generated in substantial conformity with OPPTS Test Guideline Series 830

Product Properties, applicable to my product, and in effect at the time of submission.

As a condition of registration, EPA may, by order, (1) withdraw a pending registration, (2) suspend the

registration of this product without opportunity for hearing, or (3) assess civil penalties provided for in section

14 of FIFRA for violations of section 12(a)(2)(N) of FIFRA without opportunity for hearing, if I have not

submitted to EPA within thirty (30) days of receipt of a request by the Agency, or within a specified time

agreed to by the Agency, test results of studies summarized in the “Summary Form.”

As a condition of registration, EPA may, by order, (1) withdraw a pending registration, (2) suspend the

registration of this product without opportunity for hearing, or (3) assess civil penalties provided for in section

14 of FIFRA for violations of sections 12(a)(2)(N), 12(a)(2)(Q), or 12(a)(2)(R) of FIFRA without opportunity

for hearing, if I fail to provide to EPA within thirty (30) days of receipt of a notification of error, or within

a specified time agreed to by the Agency, information that EPA determines is required to correct the error.

Type Applicant’s Name:

Uncle Sam

Title:

President

Telephone No.

Applicant’s Signature:

Date:

EPA Form 8570-37 (12-2003)

Attach-2

Epa Form 8570-37 - Self-Certification Statement For The Physical/chemical Properties - Example

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