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pdfOMB Approval No. XXXX-XXXX
Section 550 of Public Law P.L. 109-295 provides the Department of Homeland Security with authority to regulate the security of
high-risk chemical facilities in the United States. DHS has developed a Chemical Security Assessment Tool (CSAT) to:
1. Assist facilities to determine if they are regulated under Section 550 of P.L. 109-295,
2. Assist in the determination of a facility's security risk,
3. Support the development of a Security Vulnerability Assessment as required by the legislation, and
4. Develop and receive a facility's Site Security Plan.
To guard against unauthorized submission of this sensitive data on your company’s behalf, DHS requires the issuance of unique
usernames and passwords for access. This required form allows potential users to register for access to CSAT.
This form requests that user accounts be created to obtain access to the CSAT on-line screening tool. There are three user roles for
which access is granted: “Preparer”, “Submitter”, and “Authorizer”. The Preparer is authorized to enter data into the CSAT online screening tool but is not authorized to formally submit the data on the company’s behalf. This person is a qualified individual
familiar with the facility in question. The Submitter is certified by the company or corporation to formally submit the regulatory
data to DHS. The Submitter must be an officer of the corporation (or equivalent) or be designated by an officer of the corporation,
and domiciled in the United States. To gain access, each Preparer and the Submitter require the signature of an Authorizer. On
behalf of the company that owns the facility, the Authorizer verifies that the user account request for the Preparer and Submitter is
valid. The Preparer(s), Submitter, and Authorizer must sign and date this form and send it via fax to 866-731-2728 or mail
to Chemical Security Compliance Division, ATTN: CSAT User Registration, Department of Homeland Security, Building
5300, MS 6282, P.O. Box 2008, Oak Ridge, TN 37831-6282
This approach to managing user access is intended to accommodate the varied organizational structures of companies that may
have to utilize this tool. The Preparer, Submitter, and Authorizer can be the same person or unique individuals. Some facilities
may choose to have the Preparer and Submitter be the same person. Larger facilities or companies with complex organizational
structures may wish to consolidate a significant number of facility submissions through a single or multiple Submitters.
More information on the program is available at http://www.dhs.gov/chemicalsecurity
Paperwork Burden Disclosure Notice
The public reporting burden for this form is estimated to be 44.5 minutes. The burden estimate includes time for reviewing instructions,
researching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. Send comments
regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management,
Attention: Sabrina Nelson, DHS Desk Officer, U.S. Department of Homeland Security, GSA Bldg, 7th & D Street. SW Mail Stop 3725-1
Washington, D.C. 20528 (Paperwork Reduction Project (1670_XXXX). Your response is mandatory according to Public Law 109- 295
Section 550. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the
upper right corner of this form. NOTE: DO NOT send your completed form to this address.
Reg. ID: 070000067
DHS Form 9002 (4/07)
Page 1 of 3
OMB Approval No. XXXX-XXXX
Organization for Facility 1
Notification Code (if supplied):
Name of Organization: XYZ Corp
Facility 1
Name of Facility: XYZ Corp Springfield Plant
Street Address 1: 982 Woodard Ave
Street Address 2:
City: Springfield State: Maine Zip Code: 55555
County: Utila
Latitude: 20.00000
Longitude: -79.00000
Additional non-street location information:
Preparer for Facility 1
The Preparer is authorized to enter data into the CSAT on-line screening tool but is not authorized to formally submit
the data on the company’s behalf. This person is a qualified individual familiar with the facility in question.
Is the Preparer the same person as the Submitter?: Yes
First Name: Joe
Middle Initial:
Last Name: Smith
Mailing Address 1: 982 Woodard Ave
Mailing Address 2:
City: Springfield State: Maine Zip Code: 55555
Phone Number: (555) 555-5555
Phone Extension:
E-mail Address: [email protected]
Is the Preparer a U.S. Citizen?: Yes
Preparer signature and date:
Reg. ID: 070000067
DHS Form 9002 (4/07)
Page 2 of 3
OMB Approval No. XXXX-XXXX
Submitter
The Submitter is certified by the company or corporation to formally submit the regulatory data to DHS.
First Name: Joe
Middle Initial:
Last Name: Smith
Mailing Address 1: 982 Woodard Ave
Mailing Address 2:
City: Springfield State: Maine Zip Code: 55555
Phone Number: (555) 555-5555
Phone Extension:
E-mail Address: [email protected]
Is the Submitter a U.S. Citizen?: Yes
Is the Submitter an Officer of the Corporation or designated by an Officer of the Corporation?: Yes
Is the Submitter domiciled in the U.S.?: Yes
Submitter signature and date:
Authorizing Person
The Authorizer verifies that the user account request for the Submitter and each Preparer is valid on behalf of the
company that owns the facility.
First Name: Stan
Middle Initial:
Last Name: Beherly
Mailing Address 1: 982 Woodard Ave
Mailing Address 2:
City: Springfield State: Maine Zip Code: 55555
Phone Number: (555) 555-5555
Phone Extension:
E-mail Address: [email protected]
Job Title: Authorizer
Is the Authorizer a U.S. Citizen?: Yes
Is the Authorizer an Officer of the Corporation or designated by an Officer of the Corporation?: Yes
Is the Authorizer domiciled in the U.S.?: Yes
Authorizer signature and date:
070000067
Reg. ID: 070000067
DHS Form 9002 (4/07)
Page 3 of 3
OMB Approval No. XXXX-XXXX
Section 550 of Public Law P.L. 109-295 provides the Department of Homeland Security with authority to
regulate the security of high-risk chemical facilities in the United States. DHS has developed a Chemical
Security Assessment Tool (CSAT) to:
1. Assist facilities to determine if they are regulated under Section 550 of P.L. 109-295,
2. Assist in the determination of a facility's security risk,
3. Support the development of a Security Vulnerability Assessment as required by the legislation, and
4. Develop and receive a facility's Site Security Plan.
To guard against unauthorized submission of this sensitive data on your company’s behalf, DHS requires the
issuance of unique usernames and passwords for access. This required form allows potential users to register
for access to CSAT.
This form requests that an existing user account be transferred to the person listed on page 3 of this form.
There are two user roles for which access is granted: “Preparer” and “Submitter”. The Preparer is authorized
to enter data into the CSAT on-line screening tool but is not authorized to formally submit the data on the
company’s behalf. This person is a qualified individual familiar with the facility in question. The Submitter
is certified by the company or corporation to formally submit the regulatory data to DHS. The Submitter
must be an officer of the corporation (or equivalent) or be designated by an officer of the corporation, and
domiciled in the United States. The role(s) of the person being replaced will be transferred to the person
listed on page 3 of this form. To complete the transfer, the new user requires the signature of an
“Authorizer”. On behalf of the company that owns the facility, the Authorizer verifies that the user account
transfer is valid. The user to be replaced, new user, and Authorizer must sign and date this form and
send it via fax to 866-731-2728 or mail to Chemical Security Compliance Division, ATTN: CSAT User
Registration, Department of Homeland Security, Building 5300, MS 6282, P.O. Box 2008, Oak Ridge,
TN 37831-6282
More information on the program and how to fill out this form is available at
http://www.dhs.gov/chemicalsecurity
Reg. ID: CR070000001
DHS Form XXXX (4/07)
Page 1 of 2
OMB Approval No. XXXX-XXXX
New User
First Name: George
Middle Initial:
Last Name: Washington
Mailing Address1: 1600 Pennsylvania Avenue
Mailing Address2:
City: Washington State: District of Columbia Zipcode: 20202
Phone Number: (123) 123-9877
Phone Extension:
E-mail Address: [email protected]
Is this person a U.S. Citizen?: Yes
Is this person an Officer of the Corporation?: Yes
Is this person domiciled in the U.S.?: Yes
Signature and date:
Authorizing Person
The Authorizer verifies that the user account transfer is valid on behalf of the company that owns the facility.
First Name: Martha
Middle Initial:
Last Name: Washington
Phone Number: (345) 345-2344
Phone Extension:
Job Title: Administrator
Authorizer signature and date:
User to be Replaced
First Name: Dan
Last Name: Miller
Signature and date:
CR070000001
Reg. ID: CR070000001
DHS Form XXXX (4/07)
Page 2 of 2
| File Type | application/pdf |
| File Modified | 2007-05-21 |
| File Created | 2007-05-21 |