Form 9350-2 TRI form A

Form Approved OMB Number: 2070-0143
(IMPORTANT: Type or print; read instructions before completing form)

EPA
United States

Approval Expires: 03/31/2011

Page 1 of

TOXICS RELEASE INVENTORY

FORM A

Environmental Protection Agency

WHERE TO SEND COMPLETED FORMS: 1. TRI Data Processing Center

2.
APPROPRIATE STATE OFFICE
P. O. Box 1513
(See instruction in Appendix E)
Lanham, MD 20703-1513
ATTN: TOXIC CHEMICAL RELEASE INVENTOR Y

This section only applies if you are revising
or withdrawing a previously submitted form,
otherwise leave blank.

TRI Facility ID Number

Withdrawal (enter up to two code(s)

Revision (enter up to two code(s)

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
2.1 Are you claiming the toxic chemical identified on page 2 trade secret?

No (Do not answer 2.2; 2.2 Is this copy
Sanitized
Go to Section 3)
(Answer only if “YES” in 2.1)

Yes (Answer question 2.2;
Attach substantiation forms)

SECTION 3. CERTIFICATION

Unsanitized

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

I hereby certify that to the best of my knowledge and belief, for each toxic chemical listed in the statement, the annual repor
table amount as defined in 40 CFR
372.27 (a), did not exceed 500 pounds for this reporting year and that the chemical was manufactured, processed, or otherwise used in an amount not exceeding 1
million pounds during this reporting year.
Signature:
Date Signed:
Name and offical title of owner/operator or senior management official:

SECTION 4. FACILITY IDENTIFICATION
Facility or Establishment Name

TRI Facility ID Number
Facility or Establishment Name or MailingAddress (If different from street address)

Street

Mailing Address

City/County/State/Zip Code

City/State/Zip Code

4.1

Country (Non-US)

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

c.

4.3 Technical Contact Name

A Federal
facility

GOCO

d.

Telephone Number (include area code)

Email Address
Telephone Number (include area code)

4.4 Public Contact Name
Email Address

4.5 NAICS Code (s)

Primary

(6 digits)

a.

Dun & Bradstreet

a.

4.7 Number (s) (9 digits)

b.

c.

b.

SECTION 5. PARENT COMPANY INFORMATION
5.1 Name of Parent Company
5.2

NA

Parent Company’s Dun & Bradstreet Number

NA

EPA Form 9350 -2 (Rev . 03/2009) - Previous editions are obsolete.

d.

e.

f.

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

Page

EPA FORM A
PART II. CHEMICAL IDENTIFICATION

of

TRIFID:

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

Report

SECTION 1. TOXIC CHEMICAL IDENTITY

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

SECTION 2. MIXTURE COMPONENT IDENTITY

(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 punct
uation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

1.1

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

1.2

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

1.3

SECTION 2. MIXTURE COMPONENT IDENTITY

(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 punct
uation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY
1.1
1.2
1.3

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 structurallyscriptive.)
de

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

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.)

(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 punct
uation.)

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 structurallyscriptive.)
de

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 punct
uation.)
*See the TRI Reporting Forms and Instructions Manual for the list of PBT Chemicals (including Dioxin and Dioxin-like Compounds)

EPA Form 9350 - 2 (Rev. 0 3/2009) - Previous editions are obsolete.

(Make additional copies of this page, if needed)