Document km0zVQ4amndkY77RyLzJ6zG4y
TO: INFORMATION SECTION
PLEASE DESTROY ALL OLD FORMS
i Fill 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 final report is written.
Haskell No.: <j?Q3g
(to be assigned by Haskell Personnel)
1. Chemical Abstracts nomenclature: (V) (\
AChemical Abstracts Registry No.: fJ
2. Other namefs): L 5 Af) C fi k ) \ A M--X/V ft'T' E f)
J- L
.. a vq ..::^=s==____ ':................ ................. .......
;
3.
4. Structural formula: ^
(a) Molecular weight tJ Pv
5. Composition of mixtures by % (include all additives and solvents): ^ L UJ -- ^Q3>
n .u../...
. rr^v
lv=-jL.... ....... ...............................
....
Purity L'A %
(a) Impurities present:
7. Physical characteristics:
(a) Colon R R QtJ M
(b) Form:,
(d) b.p. at 760 mm Hg.:___ ________ (e) Density:_
(c) m.p.:_
(g) Vapor pressure at 25 degrees C:_ UNKNOWN (attach curve if available)
37 degrees C:_
(h) Vapor density.
(i) Maximum process temp.
in presence/absence of air. (delete one)
DUP040001744
Estimated
^
g. Solubility: / <0.19/
0.1% >1%
Page 2 1% -10% or >10% (w/v)
(a) Waten___________ (b) Dimethylsulfoxide: (cl Ethanol: (d) Acetone: (c) Vegetable Oil:(f) Dimethylfbxmamide;
9. Reactivity:
(a) Will there be any significant reaction with water? MO
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 adds? |V{?
10. Spedal handling instructions and/or toxicity information: 5 E f-
Ai <>
11. Will this test substance be used in a product subject to State, Federal or International
approvaI?_^g.
Please List Agency(ies) ^ p \
12, Name of person completing form and date completed: \A
Cost Center/Locadom W - W -- A
JAJ <gV~ > % 'X I 9 %
13. Name ofperson having knowledge of chemical properties ofthe test substance* Phone No.: 9-
Cost Center/Location: Dm. y O M \ CMfi.M'XC ALs>
? 7^7
14. Test Substance Submitted By: " fiT(VC Us. I\m Phrm* n 0<;
Cost Center/Location:
OphJ'T CM 6 UTf Al S,
7 //
15. General Ledger & Sub-Account Cost Code:
______________ or
9 7^
c - FOR SHIPPING PURPOSES ONLY US. DEPT. OF TRANSPORTATION HAZARD CLASS1HCATION FOR SHIPPING, LABELING, AND PACKAGING^ HAZARDOUS MATERIAL*__NO _YES (IF YES. COMPLETE CIASSIHCATION BELOW.)
Explosive CUk A____B_
Etiologtc Agent Organic Peroxide Radioactive Material Poison001 Gas, Class A Poisonous liquid. Class A Flammable Gas Nonflammable Gas Flammable Liquid If flash point is below 100F}** As defined in 49 CFRpart 173.
Oxidizer
________
Flammable SoL
'
Corrosive Material (Liquid}
Poisonous liquid. Class B Poisonous Solid, Class B
' 2ZZZH
Corrosive Material (Solid) HHZZ
Irritating Material
_______
Combustible Liquid
Other Regulated Material AJ_C_D_E
** Hash point - Tag C.C.
F.
Rev. 5/1 S/84