Tier II Inventory Form 07-10-12



? Check if information below is identical to the information submitted last year.Reporting Period: January 1 to December 31, 20 Tier TwoEmergency and Hazardous Chemical InventorySpecific Information by ChemicalFor Official Use OnlyState ID#:Date ReceivedFacility IdentificationNameMaximum No. of Occupants:? Manned?Unmanned? N/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 ? No Subject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68, Risk Management Program)? ? Yes ? No Owner 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 istrue, 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 6 to 120 hours per response. Send comments on the 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.524510715772000524510798830000524510-956945002030095-95694500EPA Form No. 8700-30OMB Control No. 2050-0072 Expiration Date: 03/31/2022Page 1 of EPA Form No. 8700-30OMB Control No. 2050-0072Page 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.Chemical Name:CAS No.EHS: Yes ?No ?? Solid ? Liquid ? Gas ? Trade Secret? Explosive? Flammable (gases, aerosols, liquids, or solids)? Oxidizer (liquid, solid or gas)? Self-reactive? Pyrophoric (liquid or solid)? Pyrophoric Gas? Self-heating? Organic peroxide? Corrosive to metal? Gas under pressure (compressed gas)? In contact with water emits flammable gas? Combustible Dust? Hazard Not Otherwise Classified? Acute toxicity (any route of exposure)? Skin corrosion or irritation ? Serious eye damage or eye irritation ? Respiratory or skin sensitization? Germ cell mutagenicity? Carcinogenicity? Reproductive toxicity? Specific target organ toxicity(single or repeated exposure) ? Aspiration hazard? Simple Asphyxiant ? Hazard Not Otherwise ClassifiedMaximum AmountRange Code:Confidential:? Yes ? No? Below Reporting Thresholds (optional)? State or LocalRequirementsAverage DailyAmountRange Code:No. of days on site:? Check if information below is identical to the information submitted last year.Mixture or Product Name:CAS No.? Not Available? Solid ? Liquid ? Gas? Trade SecretEHS: Yes ?No ?? Explosive? Flammable (gases, aerosols, liquids, or solids)? Oxidizer (liquid, solid or gas)? Self-reactive? Pyrophoric (liquid or solid)? Pyrophoric Gas? Self-heating? Organic peroxide? Corrosive to metal? Gas under pressure (compressed gas)? In contact with water emits flammable gas? Combustible Dust? Hazard Not Otherwise Classified? Acute toxicity (any route of exposure) ? Skin corrosion or irritation ? Serious eye damage or eye irritation ? Respiratory or skin sensitization? Germ cell mutagenicity? Carcinogenicity? Reproductive toxicity? Specific target organ toxicity(single or repeated exposure) ? Aspiration hazard? Simple Asphyxiant ? Hazard Not Otherwise ClassifiedMaximum Amount (Total Mixture) Range Code:Confidential:? Yes ? No? Below Reporting Thresholds (optional)? State or LocalRequirementsAverage Daily Amount (Total Mixture) Range Code:EHS(s) Name (if applicable):CAS No.No. of days on site:Maximum Amount of each EHS in the MixtureRange Code:Non-EHS(s) Name (optional):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 ................
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