Date :

(Check one section only)
[ ]POSITIVE CERTIFICATION :
    "I certify that all chemical substances in this shipment comply with all applicable rules and orders under TSCA and that I am not offering a chemical substance for entry in violation of TSCA or and 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 :

Authorised Name :

Authorised Signature : _________________________

Title :

AIR WAYBILL :

If the certifier is unsure if them chemical substance is subject to TSCA compliance, contact the environmental protection agency, TSCA Assistance Office, D. C. (202) 554-1404 between 8:30 a.m. - 5:00 p.m.. E.T

Date :