Confidential location information sheet



??Check if information below is identical to the information submitted last year.Reporting Period: January 1 to December 31, 20 Confidential Location Information Sheet Tier TwoEmergency and Hazardous Chemical InventorySpecific Information by ChemicalFor Official Use Only State ID#:Date ReceivedFacility IdentificationNameMaximum No. of Occupants:Manned UnmannedN/AStreetCountyCityStateZipLatitudeLongitudeNAICS CodePhone Number (optional)()Dun & Bradstreet NumberTRI Facility ID:RMP Facility ID:N/A? N/ASubject to Emergency Planning under Section 302 of EPCRA (40 CFR part 355)?? Yes? NoSubject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68, Risk Management Program)?? Yes? NoOwner or Operator InformationParent Company Information (optional)NameNameDun & Bradstreet Number:AddressAddressPhone NumberEmail()Phone NumberEmail()Facility Emergency Coordinator (if applicable)Tier II Information ContactNameTitleNameTitleEmail AddressEmail AddressPhone Number24-hour Phone()()Phone Number()Emergency ContactsNameNameTitleTitlePhone Number24-hour Phone()()Phone Number24-hour Phone()()Email AddressEmail AddressCertification (Read and sign after completing all sections)Reporting RangesWeight Range in poundsI certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through, and that based on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate and complete.Name and official title of owner/operator OR owner/operator’s authorized representativeSignatureDate SignedRange CodeFromTo010990210049903500999041,0004,999055,0009,9990610,00024,9990725,00049,9990850,00074,9990975,00099,99910100,000499,99911500,000999,999121,000,0009,999,9991310,000,000Greater than 10 millionThe public reporting and recordkeeping burden for this collection of information is estimated to range from 10 to 120 hours per response. Send comments onthe Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T),1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.EPA Form No. 8700-30OMB Control No. 2050-0072 Expiration Date: 3/31/2022Page 1 of ????84769451250855EPA Form No. 8700-30OMB Control No. 2050-0072 Expiration Date: 3/31/2022Page of Chemical DescriptionPhysical HazardsHealth HazardsInventoryType of StorageStorage Conditions (Pressure, Temperature)Storage LocationsAdditional Reporting Information (Optional)Check if information below is identical to the information submitted last year.ExplosiveFlammable (gases, aerosols, liquids, or solids)Oxidizer (liquid, solid or gas)Self-reactivePyrophoric (liquid or solid)Pyrophoric GasSelf-heatingOrganic peroxideCorrosive to metalGas under pressure (compressed gas)In contact with water emits flammable gasCombustible DustHazard Not Otherwise ClassifiedAcute toxicity (any route of exposure)Skin corrosion or irritationSerious eye damage or eye irritationRespiratory or skin sensitizationGerm cell mutagenicityCarcinogenicityReproductive toxicitySpecific target organ toxicity(single or repeated exposure)Aspiration hazardSimple AsphyxiantHazard Not Otherwise ClassifiedMaximum AmountRange Code:Confidential: YesNoBelow ReportingThresholds (optional)Chemical Name:CAS No.EHS: Yes No Average DailyAmountRange Code:State or LocalRequirements? Solid ? Liquid? GasNo. of days on site:? Trade SecretCheck if information below is identical to the information submitted last year.Mixture or Product Name:ExplosiveFlammable (gases, aerosols, liquids, or solids)Oxidizer (liquid, solid or gas)Self-reactivePyrophoric (liquid or solid)Pyrophoric GasSelf-heatingOrganic peroxideCorrosive to metalGas under pressure (compressed gas)In contact with water emits flammable gasCombustible DustHazard Not Otherwise ClassifiedAcute toxicity (any route of exposure)Skin corrosion or irritationSerious eye damage or eye irritationRespiratory or skin sensitizationGerm cell mutagenicityCarcinogenicityReproductive toxicitySpecific target organ toxicity(single or repeated exposure)Aspiration hazardSimple AsphyxiantHazard Not Otherwise ClassifiedMaximum Amount (Total Mixture) Range Code:Confidential:Yes NoBelow Reporting Thresholds (optional)CAS No.Not Available? Solid ? Liquid ? GasAverage Daily Amount (Total Mixture) Range Code:State or LocalRequirements? Trade SecretEHS: YesNoEHS(s) Name (if applicable):No. of days on site:CAS No.Non-EHS(s) Name (optional):Maximum Amount of each EHS in the MixtureRange Code:????Optional Attachments:? I have attached a site plan? I have attached a list of site coordinate abbreviations? I have attached a description of dikes and other safeguard measures ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download