Form EPA Form 9350-2 EPA Form 9350-2 TRI Form A

Draft

Form Approved OMB Number: 2070-

(IMPORTANT: Type or print; read instructions before completing form)

EPA

Page 1 of

Approval Expires:

TOXIC RELEASE INVENTORY

TRI Facility ID Number

FORM A

United States
Environmental Protection Agency

WHERE TO SEND COMPLETED FORMS: 1. TRI Data Processing Center
P. O. Box 1513
Lanham, MD 20703-1513

2. APPROPRIATE STATE OFFICE
(See instruction in Appendix E)

This section only applies if you are revising or
Revision (enter up to two code(s))
Withdrawal (enter up to two code(s))
withdrawing a previously submitted form,
otherwise leave bank.
IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.

PART 1. FACILITY IDENTIFICATION INFORMATION
SECTION 1. REPORTING YEAR
SECTION 2. TRADE SECRET INFORMATION
Are you claiming the toxic chemical identified on page 2 trade secret?
Yes (Answer question 2.2;
No (Do not answer 2.2;
Attach substantiation forms)
Go to Section 3)

2.1

SECTION 3. CERTIFICATION

2.2

Unsanitized
Sanitized
Is this copy
(Answer only if “YES” in 2.1)

(Important: Read and sign after completing all form sections.)

Pursuant to 40 CFR 372.27(a)(1), “I hereby certify that to the best of my knowledge and belief for the toxic chemical(s) listed in this
statement, for this reporting year, the annual reportable amount for each chemical, as defined in 40 CFR 372.27(a)(1), did not exceed 5,000
pounds, which included no more than 2,000 pounds of total disposal or other releases to the environment, and that the chemical was
manufactured, or processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year;” and/or
Pursuant to 40 CFR 372.27(a)(2), “I hereby certify that to the best of my knowledge and belief for the toxic chemical(s) of special concern
listed in this statement, there were zero disposals or other releases to the environment (including disposals or other releases that resulted from
catastrophic events) for this reporting year, the “Annual Reportable Amount of a Chemical of Special Concern” for each such chemical, as
defined in 40 CFR 372.27(a)(2), did not exceed 500 pounds for this reporting year, and that the chemical was manufactured, or processed, or
otherwise used in an amount not exceeding 1 million pounds during this reporting year.”
Signature:
Date Signed:
Name and offcial title of owner/operator or senior management official:

SECTION 4. FACILITY IDENTIFICATION
TRI Facility ID Number

4.1
Facility or Establishment Name

Facility or Establishment Name or Mailing Address (If different from street address)

Street

Mailing Address

City/County/State/Zip Code

Country (Non-US)

City/State/Zip Code
c.

4.2 This report contains information for: (Important: Check c or d if applicable)

A Federal
facility

GOCO

d.

Telephone Number (include area code)

Technical Contact Name

4.3
Email Address
Public Contact Name

4.4

Telephone Number (include area code)

Email Address

4.5 NAICS Code (s)
(6 digits)
Dun & Bradstreet
4.6 Number (s) (9 digits)

Primary

a.

b.

a.
b.

SECTION 5. COMPANY INFORMATION
5.1 Name of Parent Company

NA

5.2 Parent Company’s Dun & Bradstreet Number

NA

EPA Form 9350 -2 (Rev. 11/2007) - Previous editions are obsolete.

c.

d.

e.

f.

Page

(IMPORTANT: Type or print; read instructions before completing form)

EPA FORM A
PART II. CHEMICAL IDENTIFICATION

of

TRI Facility ID Number:

Do not use this form for reporting Dioxin and Dioxin-like Compounds*

SECTION 1. TOXIC CHEMICAL IDENTITY
1.1

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
1.3 Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

(Important: DO NOT complete this section if you completed Section 1 above)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY
1.1
1.2

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)
Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

1.3

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

(Important: DO NOT complete this section if you completed Section 1 above)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.1
1.2
1.3

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

(Important: DO NOT complete this section if you completed Section 1 above.)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.1
1.2

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

1.3

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

(Important: DO NOT complete this section if you completed Section 1 above.)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

*See the TRI Reporting Forms and Instructions Manual for the TRI-listed Dioxin and Dioxin-like Compounds
EPA Form 9350 -2 (Rev. 11/2007) - Previous editions are obsolete.

(Make additional copies of this page, if needed)