COMPLETING THE REPORT FORM
BLOCK I. CERTIFICATION STATEMENT AND SIGNATURE
The Chief Executive Officer (CEO) must sign the certification statement on behalf of the reporting company. The CEO's name and title should be typed or printed on the Name and Title line of BLOCK 1. For multiple nominations, a letter signed by the CEO identifying a designate to sign nomination forms may be provided.
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BLOCK II. CORPORATE HEADQUARTERS
Corporate headquarters is the headquarters address of a business entity nominating a substance to the confidential NDSL. The name of the corporation, as well as the full address of the main office, must be included.
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BLOCK III. PRINCIPAL TECHNICAL CONTACT
Enter the name, address and telephone number of the person whom Environment Canada may contact for clarification of information submitted on the Report Form.
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BLOCK IV. SPECIFIC SUBSTANCE NAME
The Specific Substance Name should be a recognized chemical name, established in accordance with chemical
nomenclature rules of either the International Union of Pure and Applied Chemistry (I.U.PA.C.) or the Chemical Abstracts
Service(C.A.S.) Collective Index. Ambiguous or incomplete names are not appropriate for substance identification. Information
regarding substance name requirements can be found in chapter 5 of the Environment Canada publication Reporting for the
Domestic Substances List. The name entered must be the same as the complete substance name on the substantiating
documentation.
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BLOCK V. NUMERICAL IDENTIFICATION
TSCA ACCESSION NUMBER. EPA assigns a unique five-digit accession number to each confidential chemical identity on the TSCA Inventory. This TSCA Accession Number should be entered in Block V. This number need not be included if a PMN or
EPA Form C Number is entered in the appropriate space and a copy of the form provided as substantiating documentation.
PMN OR EPA FORM C NUMBER. Enter a check in the appropriate block to indicate which number is entered in the space below. If a PMN number is entered, a copy of a PMN (EPA Form No. 7710-25) along with copies of correspondence linking the substance identity, to a PMN number is to be provided as substantiating documentation (this will most often be the appropriate sections of the PMN along with copies of EPA correspondence attesting to a PMN number). If an EPA Form C number is
entered, a copy of a U.S. EPA Chemical Substance Inventory Report Form C (EPA Form No. 7710-3C) is to be provided as
substantiating documentation; the serial number on the EPA Form C should be clearly legible and match the number entered on
the form.
CAS REGISTRY NUMBER. If assigned, enter the Chemical Abstracts Service (CAS) Registry Number for the substance
provided in BLOCK IV. Include hyphens.
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BLOCK VI. PROPOSED MASKED NAME
Enter the proposed masked name for the NDSL in the space provided. Procedures for structuring a proposed masked name for The NDSL are identical to those for the DSL and are included in Appendix III of the Environment Canada guideline document, Reporting for the Domestic Substances List. Failure to submit a proposed masked name according to these
guidelines will void the nomination.
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BLOCK VIl. TSCA INVENTORY NAME
Enter the name used in the confidential section of TSCA Inventory, to mask the identity of the substance entered in BLOCK IV. This TSCA Inventory Name must be entered when substantiating documentation other than a PMN or Inventory
Report Form C is being provided. If providing a PMN or U.S. EPA TSCA Form C (Block V), may be omitted.
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BLOCK VIII. SUPPORTING DOCUMENTATION
Please indicate the number of attachments in the box provided under supporting documentation.
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