Document 0qXDvodDBXKQ37o9k8Ox6aOGR

TO: INFORMATION SECTION PLEASE DESTROY ALL OLD FORMS HASKELL LABORATORY TEST SUBSTANCE EVALUATION FORM L Fill out a test substanoe evaluation form as completely as possible for eac)t-test substance submitted ii. If a test substance is being submitted for mutagenicity testing, pay special attention to Sections 6,8 and 9. iii. Unless otherwise requested, test substances will he returned to submitter within six months after die final report is written. Haskell No.: SLAd*6 4 (to be assigned by Haskell Personnel) 1. Chemical Abstracts nomenclature: \JA . . . . . ...... ______ _ Chemical Abstracts Registry No.: AJ f\ 2. Other name(s): L, ^^TAMXa /AITB <0 WTTM' iffOO PpA^ A3. Cost Center identification code and/or lot number: A/ 4. Structural formula: * (a) Molecular weight A/A 5. Composition of mixtures by % (include all additives and solvents!: k) A 6. Purity A/'/) % (a) Impurities present: AJ A 7. Physical characteristics: A/A (a) Colon (b) Form: "So Lt J (c) m.p.: AJ /A (d) b.p. at 760 mm Hg.: (e) Density: A . (f) pH: ' .AJ M (g) Vapor pressure at 25 degrees C:_ Ly/> 37 degrees C: AJjA (h) Vapor density UNKNOWN (attach curve if available) AM (i) Maximum process temp. in presence/absence of air. (delete one) DUP040001736