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BFGoodrich__________________________________________________________/}aj 449 ? The BFGoodrich Company 3925 Embassy Partway Akron. Ohio 44313-1799 AX ' - August 30, 1990 Toxicological Services National Sanitation Foundation P.O. Box 1468 Ann Arbor, Michigan 48106 Dear Gentlereader: I am enclosing completed Material Formulation Confidential (^Report forms for the following Geon^R' compounds for various users: XT '87407-000-0078 87431 Blue 440 \ 87322 Grey 260 Xl/\ 85796 White 124 \ 875333 Trans 006 ! 8761-273 K' S' ) J The composition of the above Geon compounds is confidential to BFGoodrich and therefore subject to the generic secrecy agreement signed by the BFGoodrich Company and the National Sanitation Foundation, October 24, 1979. Sincerely, THE BFGOODRICH COMPANY W. c. Bachtel Toxicologist Environment, Health and Safety Management Systems 0830-1/jp cc: J. C. Kelley - CL-OTM-3 Z0874001 BFG07617 NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code FM00146-001 Company Number 20080 Regional Office 02 Issue Date 07/17/90 Regional Representative J. ARMBRUSTER * * * DO NOT DUPLICATE Standard Number 51 CBI Code 03343 I. PROGRAM PARTICIPANT B F GOODRICH MR. W. C. BACHTEL 3925 EMBASSY PARKWAY AKRON, OH 44313 Plant At: AKRON, OH 44313 II. SUPPLIER Basic Material Supplier Material Type Complete Formulation Id B.F. GOODRICH, GEON VINYL DIV PVC GEON 87533 TRANS 006 ( 1 Natural [X] Precolored: X [ 1 See Form: III. TYPE OF FOOD CONTACT (Check all that apply) [ ] Dry Solids [ j Aqueous [ ] Acidic (pH < or = 5.0} [ j Dairy Products [ 1 Oil [ 1 Beverages > 0, but < or = 8% alcohol [ 1 Beverages >8% alcohol ( ] Splash Zone IV. TEMPERATURE (Check one) [ ] < or - 45 'F [ ] > 180'F to 212 'F [ ] > 45'F to 100'F [ } > 100'F to 180'F [ 3 >212'F (specify maximum _____ _'F) V. FORMULATION REVIEW NON-ACCEPTANCE. We are unable to accept this component of your equipment because: The formulation information provided by the supplier is not sufficient to permit complete review. An appropriate section of the U.S. Code of Federal Regulations, Title 21 (Food and Drugs) is not cited for each ingredient. Specific Title 21 citations are generally required for a food zone material. Section III PART(S). Please provide the following information: The type of contact the material is expected to have. The temperature (range) the material is exposed to. Section V. Please provide complete disclosure of the ingredients used (by chemical name). Please resubmit on the enclosed form. G BALL Toxicology Services 20874002 BFG07618 NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code FM00146-001 Company Number 20080 Regional Office 02 Issue Date 07/17/90 RESUBMITTAL * * * DO NOT DUPLICATE Standard Number 51 CBI Code _ *** I. PROGRAM PARTICIPANT B F GOODRICH MR. W. C. BACHTEL 3925 EMBASSY PARKWAY AKRON, OH 44313 Plant At: All Geon plants II. SUPPLIER Basic Material Supplier Material Type Complete Formulation Id B.F. GOODRICH, GEON VINYL DIV PVC GEON 87533 TRANS 006 [ ] Natural [ j Precolored: [ ] See Form: III. TYPE OF FOOD CONTACT (Chock all that apply) ( ) Dry Solids [ ] Aqueous [ ] Acidic (pH < or * 5.0) [ ] Dairy Products t ] Oil [ ] Beverages > 0, but < or = 8% alcohol 1-1 Beverages > 8% alcohol , .... IV. TEMPERATURE (Check one) [ ] < or *= 45'F. i ] > 180'F to 212 'F ; .IIIIF m&A l ] > 45*F to 100 'F l j >2l23lv(specify maximum pmm [ J >'100'F to 180'F >. *F) V. COMPOSITION OF FORMULATION AND PERTINENT DATA -- USE REVERSE SIDE. To Be Completed By-Basic Material/Pigment Supplier. // VI. CERTIFICATION ; ^.* It is herein certified that this material is intended for ,tfes specific end use application (s) It is further certified.,,that the iftfprmation : provided is accurate and complete andr -in of materials intended for food'rone application5the material meatar'-tfee requirements'^ the Federal Food, Drug, and Cosmetic Act as amended. BASIC MATERIAL SUPPLIER Company______ BFGoodrich Company - Geon Vinyl Division Signature J. C. Kelley Title Technical Service Manager ' Address Telephone 6100 Oak Tree Blvd. Cleveland. OH 44131 (216) 447-6000 FAX (216) 447-6392 Date___ August 30, 199Q: Seal in the BLUE envelope provided, insert in an outer envelope and MAIL TO: Toxicology Services National Sanitation Foundation P.O. Box 1468 Ann Arbor, MI 48106 Fage (1) 2087-4003 BFGO'7619 v COMPOSITION OF FORMULATION AND PERTINENT DATA Chemical Description of Ingredient (Do NOT Use Trade Names) Please verify the material typefcolor and formulation identification referenced in Section IV on the reverse. Parts by Weight Supplier Section of the U.S. Code of Federal Regulations (21 CFR)* under which accepted. Geon 87533 Trans 006 Polyvinyl chloride Methylmethacrylate butadiene styrene Acrylonitrile butadiene styrene Methylmethacrylate butyl methacrylate butylacrylate Di(n-octyl)tin 3,5'bis (isooctyl)mercapto acetate Mono and diglycerides Pentaerythritol adipate stearate Oxidized polyethylene Stearic Acid Ultramarine Violet Blue Pigment* 100.0 1.2 - 14.5 BFGoodrich Roftn & Haas 178.3790 1.4 - 2.2 0.8 - 1.3 Akzo ChemieAmerica Rohm & Haas 178.3790, 177.1010, 177.1020 178.3790 2.0 - 2.4 Atochsn 178.2650 0.6 - 0.8 0.2 - 0.4 Lonza Inc. Henkel 184.1505, 182.0 178.3690 0.1 0.0 0.0 - 0.0 - 0.3 0.2 : 0.05 0.16 Allied Henkel Witoo Whitaker Clark 5 Daniels BFGoodrich 177.1620 184.1090 178.3970 *Polyvinyl chloride Epoxidized Linseed oil Ultramarine Blue 92.0 3.0 5.0 BFGoodrich American Chanical Serv. Inc. Whitaker Clark & Daniels Prior Sanctioned Prior Sanctioned 178.3970 2087400 PLEASE PROVIDE SIGNATURE/CERTIFICATION ON REVERSE SIDE. ' Available from the Superintendent of Documents, U. S. Government. Printing Office, Washington, D.C. 20402 (202-783-3238) or your local U. S. Government Printing Office outlet. Title 21 (Food and Drugs), Parts 1-99: 21 (Food and Drugs), Parts 170-199: General information and color additives (direct). Direct and indirect food additives, including ingredients for use in food contact materials. (2) BFG07620 NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code SW00314-001 Regional Office 03 Company Number 21600 Issue Date 07/06/90 Regional Representative NSWARTLEY * * * DO NOT D U P L I C A T E Standard Number 50 CBI Code I. PROGRAM PARTICIPANT HAYWARD POOL PRODUCTS INC MR. SAMUEL TOBIAS 900 FAIRMOUNT AVENUE PO BOX 18 ELIZABETH, NJ 07207 Plant At: ELIZABETH, NJ 07207 II. MODEL(S) Equipment Model Number(s) SP740DE Description of Equipment MULTIPORT VALVE III. PART(S) Description of Part(s) VALVE BODY AND COVER Part Number(s) SP740A AND SP740B Fabricated by HAYWARD Surface Area of'FAt(s) (sq. in.^4fO Part is [X] PQ#t>|||er Contact Temperature (Rte^p^brt(s) Expos'll to AO^UMT'F Area (sq, IV. SUPPLIER Basic Material $ipplfl Material Type Complete Formalinson Idl 796 White 124 [ ] Natural C ] Precol See Fo COMPOSITlOgiflF FORMULwii&N PERTINENT DATA - USE To Be Confpfped By Baswitariiftftlal/Pifient Supplier. *** NOTE&^ljpl CFR citals^^'oiP othef^l^umentation ri SE S ed. VI. CERTIFICATION " It is herein certified that this materiat''WWCISffiJfed for thelpfcific end use application. It is further certified that the information provided is accurate and complete and, that I, and the company I represent, know of no reason this material should not be used in pool/spa/hot tub water contact. Company___ ASJiC MATERIAL SUPPLIER S//A tc b Signature_ Title____ " Address___ Telephone&7.U,'wh-Cn fAx -iiL - yY7% Date _2_J_________________________________________ _________:______ _ Seal in the BLUE envelope provided, insert in an outer envelope and MAIL TO: Toxicological Services National Sanitation Foundation P.0. Box 1468 Ann Arbor, MI 48106 Page (1) BFG07621 20874005 9(U V F A P 07 RfclASK PROVIDE SIGNATURE/CERTIFICATION ON REVERSE SIDS. v* AeOllaOle Mop file Superintendent of Documents, L). S. Government, Printing Office, Weefungton, D.C. 20402 (202-783-3238) r or your local U. S. Government Printing Office outlet. Title 21 (Ftp* and Drugs), Pans i -99: \k\r '"it: 21 and Orugs), Parts 170-199: General information and color additives (direct). Direct and indirect food additives, including ingredients for use in food contact materials. (2) BFG07622 NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code SW00314-002 Company Number 21600 Standard Number 50 Regional Office 03 Issue Date 07/06/90 CBI Code ____________ Regional Representative NSWARTLEY * * * DO NOT DUPLICATE*** I. PROGRAM PARTICIPANT HAYWARD POOL PRODUCTS INC MR. SAMUEL TOBIAS 900 FAIRMOUNT AVENUE PO BOX 18 ELIZABETH, NJ 07207 Plant At: ELIZABETH, NJ 07207 II. MODEL(S) Equipment Model Number(s) SP740DE Description of Equipment MULTIPORT VALVE III. PART(S) Description of Part(s) VALVE BODY AND COVER Part Number(s) SP740A AND SP740B Fabricated by HAYWARD Surface Area of Patras) (sq. in.) 430* Part is [X] Pool ft$^r Contact Temperature (Rangj^$*ffet(s) Expos 40- IV. SUPPLIER ^ >4 Basic Material Surlier*- Material Type White Complete Formulation Id Geon 35796 White 124 rea (sq. i [ ] Natural ^ 1 1 PrecolordU Form $ V. COMPOSITION'FORMULA ANtH>ERTINENT DATA - USE RE To Be Complete By Basid /Pigahart Supplier, *** NOTE: ' $$ CFR citatf f ather diSlipjpientation reqj| SID& VI. CERTIFICATION Site. It is herein certified that this material i s'ffiterfd'ed for the specific end use application. It is further certified that the information provided is accurate and complete and, that I, and the company I represent, know of no reason this material should not be used in pool/spa/hot tub water contact. BASIC MATERIAL. SUPPLIER Company___ Signature_ Titl e____ " Address___ JJ4A Telephone_ 7W Date August 30. 1990 '4S2*'f Seal in the BLUE envelope provided, insert in an outer envelope and MAIL TO: Toxicological Services National Sanitation Foundation P.0. Box 1468 Ann Arbor, MI 48106 Page (1) BFG07623 20874007 2087400 PfcEASE PROVIDE SIGNATURE/CERTIFICATION ON REVERSE SIDE. Available fre tit# Superintendent of Documents. U. S. Government. Printing Office, Wasnmgton, D C. 20402 (202-783-3238) '' or your local U. S'. Government Printing Office outlet. Title 21 (Food and Orugs). Parts 1 -99: General information and color additives (direct). & 4 21 (J|d and Orugs), Parts 170-199: Direct and indirect food additives, including ingredients for use in food contact materials. (2) BFG07624 NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code SW00146-001 Company Number 24300 Regional Office 04 Issue Date 06/21/90 Regional Representative MDF * * * DO NOT DUPLICATE Standard Number 50 CBI Code __________ *** I. PROGRAM PARTICIPANT JACUZZI BROTHERS DIVISION MR. JEFF ROUSSEL 12401 INTERSTATE-30 PO BOX 8903 LITTLE ROCK, AR 72219-8903 Plant At: LITTLE ROCK, AR II. MODEL(S) Equipment Model Number(s) MFM AND ST SERIES Description of Equipment SAND FILTERS III. PART(S) Description of Part(s) DRAIN BUSHING & FILL PLUG AND PORT ADAPTER Part Number(s) Fabricated by JA&^ZI BROTHERS ; . .y Surface Area of-twS&Cs) (sq. in*} 30 ; Conta6R?|lfcea (sq.T Part is [X] Pool r Contact' Temperature (Range [s) Exposed to 32--104 'F IV. SUPPLIER Basic Material Supplied F. GOODRICH Material Type N ' *f$C/CLEAR Complete Formulation Id 4^407-000-0078 V. COMPOSITION OF FORMULATION AND PERTINENT DATA - USE/KNfERSE To Be Completed By Basic Naterial/Pigmtmt Supplier* *** NOTE? 21 CFR citation or other documentation required. ? VI. CERTIFICATION It is herein certified that this material is intended for the specific end use application. It is further certified that the information provided is accurate and complete and, that I, and the company I represent, know of no reason this material should not be used in pool/spa/hot tub water contact. BASIC MATERIAL SUPPLIER Company________ D F, 600VA ,c / - <$ eg tv 1/, / /// V/ V fa S ignature~ ^ / Title_____________ rsci, a-/^ is, /7 9A Address__ Telephone (, 100 04 in (216) 447-6000 /Mr' FAX (216) 447-6392 *r/ft Date August ,.2CLfc, 192Q_________________________________________________________________ Seal in the BLUE envelope provided, insert in an outer envelope and MAIL TO: Toxicological Services National Sanitation Foundation P.0. Box 1468 Ann Arbor, MI 48106 Page (1) BFG07625 72219-8903 20874009 v. COMPOSITIC N OF FORMULATKDN AND PERTIN ENT DATA Chemical Description of Ingredient (Do NOT Use Trade Names) Parts by Weight Supplier Section of the U.S. Code of Federal Regulations (21 CFR)1 under which accepted. Please verify the material type/color and formulation identification referenced in Section IV on the reverse. Geon 87407-000-0078 Polyvinyl chloride Methyl methacrylate butadiene styrene Ethyl acrylate - methyl methacrylate Dimethyl /monanethyltin isooctylmercaptoaoetates Ultramarine Violet Polyhydric alcohol diesters of oxidatively refined Montan Wax acids Mono and diglycerides Fatty acid esters Colorant* *Polyvinyl chloride Epoxidized lindseed oil Ultramarine Blue 100.00 BPGoodrich Prior Sanctioned 12.0 Kaneka Texas 178.3790 V' v Corp. <*i<fc, - 1.75 Rohm & Haas 178i;|790 2.0 0.051 0.2 Argus Carstab Whitaker Clark & : ^ Daniels,% Hoechst Celanese L sqm. 3910 178.3^ T 1.13 0.75 ^onza- Lonza it'* v i# 18*.1505 Part 172 O.iiif HE|^odrich * 92.0 5.0 :Jr #" BFGoodriich American Chemical Service 5 Whitaker ^ Clark & Daniels Prior Sanctioned Prior Sanctioned 178.3970 - > i? ..:W tf 'h. At " 20874010 PLEASE PROVIDE SIQNATURE/CERTIFICATION ON REVERSE SIDE. ' Available fwn the Superintendent of Documents, U. S. Government, Printing Office. Washington, O.C. 20402 (202-783-3238) ?' or your local, U. S. Government Printing Office outlet. ` ^ Title 21 (Pood and Drugs), Parts 1 -99: General information and color additives (direct). 21 (Pood and Drugs), Parts 170-199: Direct and indirect food additives, including ingredients for use in food contact materials. <*> BFG07626 NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code WT01279-002 Company Number 15071 Regional Office 02 Issue Date 07/31/90 Regional Representative JSA * * * DO NOT DUPLICATE Standard Number 58 CBI Code ____________ *** I. PROGRAM PARTICIPANT ECOWATER SYSTEMS MR. MARLIN FRANK ECOWATER CONSUMER PRODUCTS 1390 WOODLAWN DRIVE PO BOX 64420 ST PAUL, MN 55164 Plant At: WOODBURY, MN 55125 j. x i. .WL ulj ^ O / Equipment Model Number(s) EKS-300 Description of Equipment RO System III. PART(S) Description of Part(s) Tank Valve Part Number(s) B 71Q&429 Fabricated by Specialty Mfg. Co-. Surface Area of Part fa} (sq. in.) 3.0 IV. SUPPLIER :||| lllli*::.,. Basic Material. Supplier HF Goodrich Material Type PVC Complete Formulation^ 14 Geon 87431 Blue 440 Contact Area {sq. in.) 1,5 Ill "'III. Ilf t ] Natural . Precolored: ___ I j See Form_______ V. COMPOSITION OF FORMULATION AND PERTINENT DATA - USRr'REVERSE SIDS, To Be Completed S& Basic MateriaI /P i gment Sappliec, ,, .. . ................................... viviwiv#;:? VI. CERTIFICATION -(Check One. t*Se elterbate- Only for nofl-FDA materials Such as brass.) [ ] It is herein certified that this material is intended for the specific end cse application. It is further certified that the information provided is accurate and complete, and that the material meets the requirements of the Federal Food, Drug, and Cosmetic Act as amended. [ ] It is herein certified that this material is intended for the specific end use application. It is further certified that the information provided is accurate and complete, and.that I, and the company I represent, know of no reason this material should not be used in contact with drinking water. BASIC MATERIAL SUPPLIER Company Signature Title Address TeleDhone RPCVndri rii Company - Geon Vinyl Division DL C. Kellev Tpvhni cal_ru Mananer ^S fil OO Half Rlrn^ Clovalanri, OH 44131 (216) 447-6000 FAX (216f 447-6392 Date August 30, 1990 Seal in the BLUE envelope provided, .insert in an cuter envelope and MAIL TO: Toxicological Services P.O. Rex 1468 BFG07627 20874011 839I0DJ9 COMPOSITION OF FORMULATION AND PERTINENT DATA Chemical Description of Ingredient (Do NOT Use Trade Names) Parts by Weight Please verify the material type/color and formulation identification referenced in Section IV on the reverse. Geon 87431 Blue 440 Polyvinyl chloride Di(n-butyl)tin-bis isooctyl mercaptoacetates Methylmethacrylate butadiene styrene Ethylacrylate - methyl methacrylate Titaniun dioxide Phthalocyanine Blue Paraffin Wax 100.0 3.2 3.0 1.6 2.0 0.25 0.5 Butyl stearate 1.3 Supplier Section of the U.S. Code of Federal Regulations (21 CFR)' under which accepted._________ BFGoodrich M&T Argus Rohm & Haas Prior Sanctioned NSF Std. 14 178.3790 Rohm & Haas 178.3790 Zeon Chemica. E.I. DuPont 181.30 177 .`2600 BASF 175.300 177.2600 Hoechst- 175.3001 177.260: Celanese Rheo chem Mf< \ Frank Ross Witoo Henkel 175.05, 175.320, 175.300 177.2600 20874012 PLEASE PROVIDE SIGNATURE/CERTIFICATION ON REVERSE SIDE. ' Available from the Superintendent of Documents, U. S. Government, Printing Office. Washington, D.C. 20402 (202-783-3238) or your local U. S. Government Printing Office outlet. ^ Title 21 (Food and Drugs), Parts 1-99: General information and color additives (direct). ,9ttle 21 (Food and Drugs), Parts 170-199: Direct and indirect food additives, including ingredients for use in food contact materials. (2) NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code WT01279-001 Company Number 15071 Regional Office 02 Issue Date 07/31/90 Regional Representative JSA * * * DO NOT DUPLICATE Standard Number 58 CBI Code *** I. PROGRAM PARTICIPANT ECOWATER SYSTEMS MR. MARLIN FRANK ECOWATER CONSUMER PRODUCTS 1890 WOODLAWN DRIVE PO BOX 64420 ST PAUL, MN 55164 Plant At: WOODBURY, MN 55125 II. MODEL(S) Equipment Model Number(s) EWS-300 Description of Equipment RO System III. PART(S) Description of Part(s) Tank Valve Part Number(s) B 7100428 Fabricated by Specialty Mfg. Co. Surface Area of Part la) (sq. in,,) 3.0 Contact Ate* (sq. in.) 1.5 IV. SUPPLIER Ilf Basic Material Supplier BF Goodrich Material Type PVC Complete Formulation Id GEON 87322-260 - Grey ! l||k ill [ ] Natural Precovered: f j see Form_______ ___________ V. COMPOSITION OF F08MULATI0H AND PERTINENT DATA - USE'AEVERSE SIDlE. To Be Completed By Basic Ifekterial/Pigment Supplies* VI. CERTIFICATION'(Chfcck One. Use altercates'only for AOa-FDA materials such as brass.) [ ] It is herein certified that tftis materiai is intended for the specific end use application. It is further certified that the information provided is accurate and complete, and that the material meets the requirements of the Federal Food, Drug, and Cosmetic Act as amended. [ ] It is herein certified that this material is intended for the specific end use application. It is further certified that the information provided is accurate and complete, and that I, and the company I represent, know of no reason this material should not be used in contact with drinking water. BASIC MATERIAL SUPPLIER company Signature Title Address Telephone ___BFCVY-rir-i rrh Crmpany - <Cor>n Vinyl Di visinn J. C. Kelley ` *7/,. i n/.tr Techmrvil Sprvine Mflnsgpr 0& 6100 Ofllc Tree Rlvtl- cl wel snr) r OH 44131 (216) 447-6000 FAX (216) 447-6392 Date August 30, 1990 Seal in the ELUE envelope provided, insert in an outer envelope and MAIL TO: Trniccicri:al Services , Ua; : Ser.iiecicn Foundaticn P.O. Sex 1468 BFG07629 20874013 09Z.09d9 COMPOSITION OF FORMULATION AND PERTINENT DATA Chemical Description of Ingredient (Do NOT Use Trade Names) Parts by Weight Supplier Section of the U.S. Code of Federal Regulations (21 CFR)' under which accepted. Please verify the material type/color and formulation identification referenced in Section IV on the reverse. Geon 87322-260 Grey Polyvinyl chloride Acrylonitrile - butadiene styrene Acrylonitrile - styrene Dimethyl /moncmethyltin isooctylmercaptoaoetates Titanium dioxide Carbon black Calcium stearate N,N'Ethylene distearoylethylene diamine 100.00 13.0 3.0 1.5 2.0 0.09 2.0 1.5 BFGoodrich G.E. Prior Sanctioned 181.32 180.22 BFGoodrich 181.32 180.22 Argus Carstab 178.2Q10 E.I. Dupont 181.30 177.2600 Columbian 177.2600 Chemicals Synthetic Pdt 3. Norak Mallinkrodt Akzo Chemie- American 178.2010 Carstab : Lonza Witoo ' Akzo Charlie- American 177.1210, 181.28 PLEASE PROVIDE SIGNATURE/CERTIFICATION ON REVERSE SIDE. Available from the Superintendent of Documents, U. S. Government, Printing Office, Washington, D.C. 20402 (202-783-3238) or your local U. S. Government Printing Office outlet. 4 w Title 21 (Food and Drugs). Parts 1-99; General information and color additives (direct) %le 21 (Food and Drugs), Parts 170-199: Direct and indirect food additives, including ingredients for use in food contact materials. (2) NATIONAL SANITATION FOUNDATION MATERIAL FORMULATION CONFIDENTIAL REPORT Document Control Code FD01494-001 Company Number 32'750 Regional Office 02 Issue Date 07/31/90 Regional Representative TA * * * DO NOT DUPLICATE Standard Number 18 CBI Code ___________ *** I. PROGRAM PARTICIPANT MULTIPLEX COMPANY MR. LARRY J. ROBERTS 250 OLD BALLWIN ROAD BALLWIN, MO 63021 Plant At: BALLWIN, MO 63021 II. MODEL(S) Equipment Model Number(s) 53,54,55,56 Description of Equipment Orange Juice Dispenser III. PART(S) Description of Part(s) Tube, OJ Plastic Tank dip, Tube, Valve Inlet Disconnect, OJ Part Number(s) Plastic plastic tank (bag in box')212219,211370,211771 Fabricated by Multiplex Surface Area of Part (a) (sq. in.) Contact Area (sq. in.) 33.09 Surface is [X] Smooth Part is [X] Food 2one, Food Contact Temperature (Range) Partis) Exposed to <73 'F Type of Food/Wate r/Etc. O.J. IV. SUPPLIER Basic Material Supplier BF Gcoarich Material Type ' Grey Complete Formulation.c-I&f GEON 8761-213 Natural IPg Precolored: f j See Form V. COMPOSITION OF FORMULATION AND PERTINENT DATA - USB REVERSE SIDE. To Be Basic M&taridi/FigmentSupplier. VI. CERTIFICATION It is herein certified that this material iS'.intended for the specific end use application. It is further certified that the information ErcvidS'd .is sccursts srid comclst*? in of materials intrdd for food zone application the material meets the requirements of the Federal Food, Drug, and Cosmetic Act as amended. BASIC MATERIAL SUPPLIER Company___ Signature Via f / ___ fltf.jj.UJt. Title Addres s utn LfM- 6Uv. t (< r/ ; f S a tti(nL Te 1 c- ph on& L, - </jf 7-4 f (/ 7F AX % / U - << H 1 - Lb 0 f Date _______ 1-':--------- Seal in the BLUE envelope provided, insert, in an cuter envelope and MAIL TO: Toxicolcoicsl Services Notional Sanitation Foundation 7 .0. F1468 20874015 BFG07631 9Z.0Dd9 COMPOSITION OF formulation and pertinent data Chemical Description of Ingredient (Do NOT use Trade Names) Parts by Weight Please verify the material type/color and formulation identification referenced in Section IV on the reverse, Geon 8761-273 Polyviny chloride Styrene acrylonitrile Di(n-butyl)tin bis (isooctyl mercaptoaoetate) Titaniun dioxide Carbon black Calcium stearate 100.0 2.0 2.0 1.7 0.162 2.0 N,N'Ethylene distearoylethylene diamine Supplier Section of the U.S. Code of Federal Regulations (21 CFR)* under which accepted. BFGoodrich Prior Sanctic' BFGoodrich 180.22 181.3. M&T Argus NSF Std. 14 E.I. DuPont 181,30 177.2600 Cabot 177.2600 Synthetic Products Norak Mallinkrodt Witoo 178.2010 Carstab Lob^::::%;y Witoo Akzo Cheroie- America 177.1210 181.28 9 T 0 17.^8 0 2 PLEASE PROVIDE SIGNATURE/CERTIFICATION ON REVERSE SIDE. ' Available from the Superintendent of Documents, U. S. Government, Printing Office, Washington, D.C. 20402 (202-783-3238) or your local U. S. Government Printing Office outlet. Title 21 (Food and Drugs), Parts 1-99: * *&We 21 (Food and Drugs), Parts 170-199: General information and color additives (direct). Direct and indirect food additives, including ingredients for use in food contact materials. (2)