WERCS Professional Services
Request for SDS Preparation
Please complete form electronically and return via email to .
Information with an * is required data.
Forward all supplier/ingredient MSDSs by email to .
Lack of pertinent information may impact our ability to begin authoring.
*Today’s Date: 11/03/15 *Expected MSDS Delivery Date (Draft Version):
*Requested By: Rick Kment *Phone: 518-766-2932 *Email:
*Technical Contact: Rick Kment *Phone: 518-766-2932 *Email:
Revised 9/19/13
*Company Name: Copeland Coating Co, Inc.
*Address: PO Box 595, 3600Route 20
Nassau, NY 12123
*Phone #: 518-766-2932
*Emergency Phone #: 518-766-2932
8:00am to 5:00pm M-F EST.
*Manufacturer Name:
(If different from Company)
*Address:
*Phone #:
*Emergency Phone #:
Revised 9/19/13
*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)
*Phone #: (mandatory for outside US)
*Emergency Phone #: (mandatory for outside US)
*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.
*Product Name: Action Pave LP Sealer - Regular & Sand Fortified.
*Product Synonym(s):
*Product Code: *Recommended Use: Preserves and protects asphalt pavements.
*Is this product for professional use ONLY? X Yes No *Is this product a detergent? Yes X No
Please reference a similar product previously authored by WPS (if applicable):
*SDS Format(s):
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 X No If Yes what region(s)?:
*Language Translations Needed? Yes ** X No
If YES, please indicate the necessary languages:
Revised 9/19/13
Revised 9/19/13
AT Austrian German
BD Belgian Dutch
BE British English
BF Belgian French
BG Bulgarian
BR Brazilian Portuguese
CF Canadian French
CN Chinese Simplified
CR Croatian
CS Czech
DA Danish
DE German
EL Greek
ES Spanish
ET Estonian
FI Finnish
FR French
GA Irish English
HU Hungarian
ID Indonesian
IT Italian
JP Japanese
KO Korean
LT Lithuanian
LV Latvian
MA Malaysian
MS Mexican Spanish
NL Dutch
NO Norwegian
PL Polish
PT Portuguese
RO Romanian
RU Russian
SF Swiss French
SG Swiss German
SI Swiss Italian
SK Slovakian
SN Slovenian
SV Swedish
TA Chinese Traditional
Revised 9/19/13
Revised 9/19/13
**For customer-specific or new phrases, additional charges for translations will apply.
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.
*Do you want 100% disclosure listed on your MSDS? Yes X No
*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.
*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%.
Component Name / CAS # / Exact Weight % / Range % / C&L-notified Classification + / Trade Secret ++? / Trade Secret Name /NumberWater / 7732-18-5 / 48.54 / Yes / Yes X No
Clay M&D / 22.63 / Yes / Yes X No
LP Sealer Base / 64742-90-1 / 14.23 / Yes / Yes X No
Corsapave 34 / .12 / Yes / X Yes No
Portland Cement / 65997-15-1 / .11 / Yes / X Yes No
US Silica Sand 60 Mesh / 14.37 / Yes / Yes X No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
+ Mandatory information for EU authoring; if unknown, please note as such (do not leave blank).
++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.
*Physical State (please do not leave any properties blank; insert “n/a” if not applicable to your product):
X Liquid Gas Solid (powder) Solid (compressed) Aerosol
Color: Brownish Black Odor: Slight, Petroleum pH: Flashpoint: (°C)
Boiling Point: (°C) Melting Point: (°C) Specific Gravity: (no units, but stated at a given temp)
Viscosity: VOC (product): Coefficient of Octanol/Water Distribution:
Water Solubility: Solvent Solubility:
*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
Additional Toxicology/Ecotoxicology Data:
Please indicate details here and our Toxicologist will contact you.
*Transportation Information (please check one box below):
Product is regulated for transport (please provide shipping classification information below)
DOT
TDG
IATA
UN #
X Product is not regulated for transport
Transportation status unknown; WPS consulting needed
*Product-level EU and/or GHS Classifications (if applicable and available): No
*Have all substances at or above 1% been classified? Yes X No
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.
END OF FORM
Authorized by (electronic signature or typewritten name is acceptable): / Date:Revised 9/19/13