Document 3Q2Z7aJkxqy9oKOZdYR44rzg3

TO: INFORMATION SECTION PLEASE DESTROY ALL OLD FORMS L Fill put a test substance evaluation form as completely as possible for each test substance submitted ii. If a test substance i$ being subnutted for mutagenicity testing, pay special attention to Sections 6,8 and 9. iiL Unless otherwise requested, test substances will be returned to submitter within six months after the final report is written. Haskell No.: ___________ __ . (to be assigned by Haskell Personnel) ;.*N # 1. Chemical Abstracts nomenclature: Ao A Chemical Abstracts Registry No.: AJ ______ __ 2. Other name(s): ^ ________ ----__--------- - , 3. Cost Center identification code and/or lot number 4. Structural formula: NJ h (a) Molecular weight kJ f\ 5. Composition of mixtures by % (include all additives and solvents):. ______ "50 0 L~ --gf______ _ 6. Purity lift % (a) Impurities present: 7. Physical characteristics: (a) Colon AQDiOaJ (b) Form: ^-- (c) m.p.: (d) b.p. at 760 mm Hg.:.................. (e) Density: (f) pH: ________ (g) Vapor pressure at 25 degrees C:_ ______ 37 degrees C:______ (h) Vapor density ___ UNKNOWN (attach curve if available) (i) Maximum process temp. in presence/absence of air. (delete one) DUP040004259 Estimated 8. Solubility: C <0.1%J^y 0.1% -1% Page 2 1% -10% or >10% (w/v) (a) Water: (b) Dimethylsulfoxide: (c) Ethanol: (d) Acetone: (e) Vegetable Oil:(f) Dimethylformamide: Reactivity: (a) Will there be any significant reaction with water?. -J,,.CL If so, would the half-life be: <10 min., 10 min.-l hr.', 1 hr.-24 hrs., >24hrs. (b) Will there be any significant reaction expected with either the solvents specified in (8) or sugars or amino acids? a i r\ 10. Special handling instructions and/or toxicity information: MlSaly 11. Will this test substance be used in a product subject to State, Federal or International approval? Please List Agency(ies) Hip fit... 12. Name of person completing form and date completed: 0. Cost Center/Location:. I <?- H- 1. Ma~* X s- t /ctqq 13. Name of person having knowledge of chemical properties of the test substance: ~T:e: W Phone No.: (LliXs)'X^ 2 -7HD Cost Center/Location: _______________ . : . . 14. Test Substance Submitted Bv: P Cost Center/Location: Phone No.: (V/^ 3 62- ?U0 . ________ . .,,__________________,______ 15. General Ledger & Sub-Account Cost Code: _________ or MR: 9o^> /" - FOR SHIPPING PURPOSES ONLY - U.S. DEPT. OF TRANSPORTATION HAZARD CLASSIFICATION FOR SHIPPING. LABELING. AND PACKAGING^ HAZARDOUS MATERIAL*_NO --YES (IF YES. COMPLETE CLASSIHCATION BELOW.) (Check PRIMARY hazard applicable and identify all ether hazards by underlining.) Explosive Class A B C ___ % Etiologic Agent Organic Peroxide Radioactive Material Poisonous Gas. Class A Poisonous Liquid, Class A Flammable Gas Nonflammable Gas Flammable Liquid If flash point is below 100"F)** V. * As defined in 49 CFR part 173. Oxidizer _________ Flammable SoL _____ Corrosive Material (Liquid) '' Poisonous Liquid, Class B _____ Poisonous Solid, Class B . Corrosive Material (Solid) _____ Irritating Material ....... Combustible liquid _____ . Other Regulated Material A_B_C_D_E _ ** Flash point- Tag C.C..F. Rev. 5/18/84 DUP04C