Document 8o1KknQyXqb2aExebJLgn1DZ
TO: INFORMATION SECTION
PLEASE DESTROY ALL OLD FORMS
L FD1 out a test substance evaluation form as completely as possible for each 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 be returned to submitter within six months after the find report is written.
Haskell No.: ..... <^c?a6r7.... . ....................
(to be assigned by Haskell Personnel)
1. Chemical Abstracts nomenclature: A) A
______
. ......
Chemical Abstracts Registry No.: A f A
2. OthernameCs): LS A n CrjMTf\
A C-~^S
A/ A-T A SoT L,
3. Cost Center identification code and/or lot number:
4. Structural formula: M A
(a) Molecular weight_ Av A
Composition of mixtures by % (include all additives and solvents):.
Lf. *r>. i m
__________________________ ____
O 'iO
6. Purity Zb'A. %
(a) Impurities present:.
7. Physical characteristics:
(a) Colon
(b) Form:.
(c)m.p.:_
(d) b.p. at 760 mm Hg.:
(e) Density:.
(g) Vapor pressure at 25 degrees C:_
37 degrees C:_
(0 pH: _
(h) Vapor density.
UNKNOWN (attach curve if available)
(i) Maximum process temp.
in presence/absence of air. (delete one)
DUP040001739
Estimated 8, Solubility:
<0.1%
0.1%-1%
Page 2 1%-10% or >10% (w/v)
(a) Water: (d) Acetone:
(b) Dimethylsulfoxide: ______ fcl Ethanol:
(e) Vegetable Oil:
(f) Dimethylformamide:
9. Reactivity:
______________
(a) Will there be any significant reaction with water? NO .....
If so, would the half-life be: <10 min., 10 min.-l hr., 1 hr.-24 hrs., >24 his.
(b) Will there be any significant reaction expected with either the solvents specified in
(8) or sugars or amino acids?
10. Special handling instructions and/or toxicity information: f\
11. Will this test substance be used in a product subject to State, Federal or International
approval? M O
Please List Agency(ies) . . .... ....
..
12. Name of person completing form and date completed:
\A (\ to K tv'
K M "TO U- ^
Cost Center/Location:______
. ._______
\ jiW'l
13. Name of person having knowledge of chemical properties of the test substance:
T/' c l \A. A. t\;
Phone No.: % - 5 7/-?7 6 i
Cost Center/Location: Cy M
'V^
14. Test Substance Submitted Bv:~T. & 1* ~N CL (A At \l Phone No.: j?-5 ? Cost Center/Location: fU fc M.T C. /\ L ^_____ .
/
15. General Ledger & Sub-Account Cost Code;
or MR: Q ^ 21-
. poR s h ip p in g p u r p o s e s o n l y -
US. DEPT. OF TRANSPORTATION HAZARD CLASSIFICATION FOR SHIPPING. LABELING, AND PACKAGING HAZARDOUS MATERIAL*__NO --YES (IF YES. COMPLETE CUSSIFICATIONBELOW.L (Check PRIMARY hazard applicable and Identify all ocher hazards by undedilning.) Explosive Clast A___B C_____
\
Eiiologic Agent Organic Peroxide Radioactive Material Poisonous Gar, Clats A Poisonous Liquid, Class A Flammable Gas Nonflammable Gas Flammable liquid If flash pant is below I00F)** As defined in 49 CFR part 173.
V.
Oxidizer
,
Flammable SoL
.
Corrosive Material (Liquid) ______
.
Poisonous Liquid, Class B
.
Poisonous Solid, Class E
______
Corrosive Material (Solid)
______
Irritating Material
.
Combustible Liquid
_____
Other Regulated Material A B_jp_D_E__
** Hash point - Tag CC.F.
Rev. 5/1 S/84
DUP040001740