Document zdZENaB2agowBzv9EOKg1B880

TO: INFORMATION SECTION PLEASE DESTROY ALL OLD FORMS L Fill out a test substance evaluation form as completely as posable for each test substance submitted u. 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 bereturned to submitter within six months after the final report is written Haskell No.: ^?038'<r (to beassigned by Haskell Personnel) 1. Chemical Abstracts nomenclature: <V ) (X_______________ .. Chemical Abstracts Registry No.: U A 2. Othernaroefs): LEAfo Cj O aJ~TAM-*XN ft'T'E Fi JL L - ec * .............. (a) Molecular weight AJ ftv 5. Composition of mixtures by % (include all additives and solvents!*-- Pc\ - 3000 L fe ft ft [ A 3 5" AfcS&MML 6. Purity A % (a) Impurities present:. 7. Physical characteristics: (a) Color. a&OVJ AJ (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 presenee/absence of air, (delete one) DUP040001746 Estimated 8. Solubility: / 0.1%-1% Page 2 1%-10% or >10% (w/v) fal Water: fdl Acetone: fb) Dimethvlsulfoxide: (el Vegetable Oil: (c) Ethanoh(f) Dimethvlfonnamide: 9. Reactivity: (a) Will there be any significant reaction with water? MO -- If so, would the half-life be: <10 min., 10 xnin.-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? (V/Q 10. Special handling instructions and/or toxicity information: M^J)S 11. Will, this test substance be used in a product subject to State, Federal or International approval? '**&> Please List Agency(ies) jft FV_ 12. Name of person completing form and date completed: , Cost Center/Location^ 1 ^ - W - \ 13. Name of person having knowledge of chemical properties ofthe test substance: TIMOTH1 ft i : NG- M A a / Phone No.: 5^/- Cost Center/Location: Cm6 H'XC AL s> _______ 14. Test Substance Submitted By: ~T- ^>X(VC Mv Phone No.: gT;7/-9 ? Cost Center/Location: OoaJ*T 6MTC Al S 15. General Ledger & Sub-Account Cost Code:.____________ _________or MR: i 7 V & / - FOR SHIPPING PURPOSES ONLY - U-S.DEPT. OF TRANSPORTATION HAZARD CLASSIFICATION FOR SHIPPING. LABELING. AND PACKAGING^ HAZARDOUS MATERIAL*_NO --YES (IF YES. COMPLETE CLASSIFICATION BELOW.) (Check PRIMARY hazard applicable and identify U ether hazard! by underiilning.) Explosive Clais A 8_____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 100F)** 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_i>_JE_ * Hash point-Tag CC. F. Rev.5/1 S/84 DUP040001747 J