<p> WERCS Professional Services Request for SDS Preparation</p><p>Please complete form electronically and return via email to [email protected]. Information with an * is required data. Forward all supplier/ingredient MSDSs by email to [email protected]. Lack of pertinent information may impact our ability to begin authoring.</p><p>*Today’s Date: 10/15/15 *Expected MSDS Delivery Date (Draft Version): </p><p>*Requested By: Rick Kment *Phone: 518-766-2932 *Email: [email protected]</p><p>*Technical Contact: Rick Kment *Phone: 518-766-2932 *Email: [email protected]</p><p>*Company Name: Copeland Coating Co, Inc. *Manufacturer Name: *Address: PO Box 595, 3600Route 20 (If different from Company) Nassau, NY 12123 *Address: </p><p>*Phone #: 518-766-2932 *Phone #: </p><p>*Emergency Phone #: 518-766-2932 *Emergency Phone #: 8:00am to 5:00pm M-F EST.</p><p>*Importer Name: (mandatory for outside US) *Email Address: (mandatory for outside US) (Must be a local address for each applicable region) *Address: (mandatory for outside US) </p><p>*Phone #: (mandatory for outside US) </p><p>*Emergency Phone #: (mandatory for outside US) </p><p>*Do you want your company logo added to the MSDS? Yes X No If yes, please forward your company or product logo in .jpg format via email along with the SDS request form.</p><p>*Product Name: Asphalt Tack Coat</p><p>*Product Synonym(s): </p><p>*Product Code: *Recommended Use: As a bonding agent for hot or cold plant mix, road mix, slurry seal coat, tack coat, fog seal, dust layer, or mulch. </p><p>*Is this product for professional use ONLY? X Yes No *Is this product a detergent? Yes X No Revised 9/19/13 Please reference a similar product previously authored by WPS (if applicable): </p><p>*SDS Format(s):</p><p>GHS – Please specify region: US China Taiwan Korea Japan North America (US non-GHS, Canada & Mexico) Latin America (Please specify country/countries): Europe – CLP (default for substances) Europe – Dangerous Preparations Directives, DPD (default for mixtures) Other (Please specify format and/or region): GHS labels needed? Yes No If Yes what region(s)?: </p><p>*Language Translations Needed? Yes ** X No</p><p>If YES, please indicate the necessary languages:</p><p>AT Austrian German ET Estonian NO Norwegian BD Belgian Dutch FI Finnish PL Polish BE British English FR French PT Portuguese BF Belgian French GA Irish English RO Romanian BG Bulgarian HU Hungarian RU Russian BR Brazilian Portuguese ID Indonesian SF Swiss French CF Canadian French IT Italian SG Swiss German CN Chinese Simplified JP Japanese SI Swiss Italian CR Croatian KO Korean SK Slovakian CS Czech LT Lithuanian SN Slovenian DA Danish LV Latvian SV Swedish DE German MA Malaysian TA Chinese Traditional EL Greek MS Mexican Spanish ES Spanish NL Dutch</p><p>**For customer-specific or new phrases, additional charges for translations will apply.</p><p>STATEMENT OF CONFIDENTIALITY: Information delivered hereunder will be used by WERCS Professional Services solely to prepare the MSDS, and not for any other purpose. Further, such information will be held by WERCS Professional Services in the strictest confidence in accordance with the terms of the confidentiality section of the Work Order.</p><p>Revised 9/19/13 *Do you want 100% disclosure listed on your MSDS? Yes X No</p><p>*Please specify if you would like ranges or an exact % displayed X Range Exact % **NOTE: Some regulations may require exact % to be disclosed for hazardous components. If ranges are requested but not specified below, WHMIS ranges will be used.</p><p>*List all ingredients and percentages for the post-reaction formulation. Include any suspected contaminants and ALL ingredients in the finished product in trace amounts. Formula must total to 100%.</p><p>Component Name CAS # Exact Range % C&L-notified Trade Secret ++? Trade Secret Weight % Classification + Name /Number 89.83 Yes Yes X No Water 10.17 Yes Yes X No EM 50 Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>Yes No </p><p>+ Mandatory information for EU authoring; if unknown, please note as such (do not leave blank).</p><p>++A trade secret is any confidential information about your product or chemical that your company has protected as a secret for business purposes. Trade secrets must be confidential information known only to your company, and should provide an advantage over competitors who do not have the information. Information that is commonly known in your industry should not be claimed as a trade secret. Trade secret may be different for each country in Europe. You can apply for trade secret permission.</p><p>Revised 9/19/13 *Physical State (please do not leave any properties blank; insert “n/a” if not applicable to your product):</p><p>X Liquid Gas Solid (powder) Solid (compressed) Aerosol</p><p>Color: Black Odor: Organic pH: Flashpoint: (°C)</p><p>Boiling Point: ~ 605 F (°C) Melting Point: (°C) Specific Gravity: (no units, but stated at a given temp)</p><p>Viscosity: VOC (product): Coefficient of Octanol/Water Distribution: </p><p>Water Solubility: Solvent Solubility: </p><p>*Is Product-Level LD50/LC50 information available? Yes (Please provide below) X No LD50 Oral (Rat mg/kg) LD50 Dermal (Rabbit mg/kg) LC50 Inhalation (Rat) Dust/Mist (mg/L) Vapor (ppm) 4 hours 2 hours 1 hour</p><p>Additional Toxicology/Ecotoxicology Data: Please indicate details here and our Toxicologist will contact you.</p><p>*Transportation Information (please check one box below): Product is regulated for transport (please provide shipping classification information below) DOT TDG IATA UN # </p><p>X Product is not regulated for transport Transportation status unknown; WPS consulting needed</p><p>*Product-level EU and/or GHS Classifications (if applicable and available): No *Have all substances at or above 1% been classified? Yes X No </p><p>For EU and/or GHS authoring, please provide the appropriate EU and/or GHS classification for each substance. If a substance is not classified and WPS has to self-classify the substance, the WPS hourly regulatory consulting rate will apply for time needed to research and provide classification. </p><p>END OF FORM Authorized by (electronic signature or typewritten Date: name is acceptable): </p><p>Revised 9/19/13</p>