United States
Environmental Protection Agency
FORM R
Section 313 of the Emergency Planning and Community
Right-to-Know Act of 1986, also Known as Title III of the
Superfund Amendments and Reauthorization Act
WHERE TO SEND COMPLETED FORMS:
1. TRI Data Processing Center 2. APPROPRIATE STATE OFFICE
P. O. Box 1513
(See instructions in Appendix E)
Lanham, MD 20703-1513
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?
Yes (Answer question 2.2;
Attach substantiation forms)
No (Do not answer 2.2;
Go to Section 3)
2.2
Is this copy
Sanitized
Unsanitized
(Answer only if “YES” in 2.1)
SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)
I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the submitted information is true and
complete and that the amounts and values in this report are accurate based on reasonable estimates using data available to the preparers of this report.
Name and official title of owner/operator or senior management official:
Signature
:
Date Signed:
SECTION 4. FACILITY IDENTIFICATION
4.1
TRI Facility ID Number
Facility or Establishment Name
Facility or Establishment Name or Mailing Address (If different from street address)
Street
Mailing Address
City/State/Zip Code
Country (Non-US)
4.2
This report contains information for:
(Important: Check a or b; check c or d if applicable)
b.
An entire
facility
Part of a
facility
c.
A Federal
facility
d.
GOCO
4.3
Technical Contact Name
Telephone Number (include area code)
4.4
Telephone Number (include area code)
4.5
NAICS Code (s)
(6 digits)
Primary
a. b. c. d. e. f.
4.6
Dun & Bradstreet
Number (s) (9 digits)
SECTION 5. PARENT COMPANY INFORMATION
5.1
5.2
Name of Parent Company
Parent Company’s Dun & Bradstreet Number
NA
NA
EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.
Email Address
Public Contact Name
City/County/State/Zip Code
TRI Facility ID Number
Toxic Chemical, Category or Generic Name
EPA
Form Approved OMB Number: 2070-0093
(IMPORTANT: Type or print; read instructions before completing form)
Approval Expires: 03/31/2011
Page 1 of 5
a.
b.
Withdrawal (enter up to two code(s))
Revision (enter up to two code(s))
a.
This section only applies if you are
revising or withdrawing a previously
submitted form, otherwise leave blank.
Email Address
Form Approved OMB Number: 2070-0093
(IMPORTANT: Type or print; read instructions before completing form)
Approval Expires: 03/31/2011
Page 2 of 5
FORM R
PART II. TOXIC CHEMICAL RELEASE INVENTORY REPORTING FORM
2.1
SECTION 3. ACTIVITIES AND USES OF THE TOXIC CHEMICAL AT THE FACILITY
(Important: Check all that apply.)
4.1
EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.
TRI Facility ID Number
Toxic Chemical, Category or Generic Name
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.)
1.3
Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)
SECTION 1. TOXIC CHEMICAL IDENTITY
(
Important: DO NOT complete this section if you completed Section 2 below.)
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 punctuation.)
3.1
Manufacture the toxic chemical:
3.2
Process the toxic chemical:
Otherwise use the toxic chemical:
3.3
Produce
a.
b.
Import
If produce or import
c.
d.
e.
f.
For on-site use/processing
For sale/distribution
As a byproduct
As an impurity
a .
b.
c.
d.
e.
As a reactant
As a formulation component
As an article component
Repackaging
As an impurity
a.
b.
c.
As a chemical processing aid
As a manufacturing aid
Ancillary or other use
SECTION 4. MAXIMUM AMOUNT OF THE TOXIC CHEMICAL ON SITE AT ANY TIME DURING THE CALENDAR YEAR
(Enter two digit code from instruction package.)
SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ONSITE
A. Total Release
(pounds/year*)
(Enter a range code** or estimate)
B. Basis of Estimate
(enter code)
C. % From Stormwater
5.1
Fugitive or non-point
air emissions
NA
5.2
Stack or point
air emissions
NA
5.3
Discharges to receiving streams or
water bodies (enter one name per box)
Stream or Water Body Name
5.3.1
5.3.2
5.3.3
If additional pages of Part II, Section 5.3 are attached, indicate the total number of pages in this box
and indicate the Part II, Section 5.3 page number in this box.
(example: 1,2,3, etc.)
*For Dioxin or Dioxin-like compounds, report in grams/year.
** Range Codes: A= 1-10 pounds; B= 11-499 pounds; C= 500-999 pounds.
FORM R
PART II. CHEMICAL - SPECIFIC INFORMATION (CONTINUED)
EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.
TRI Facility ID Number
Toxic Chemical, Category or Generic Name
Page 3 of 5
SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON SITE
(continued)
NA
A. Total Release
(pounds/year*) (enter range
code ** or estimate )
B. Basis of Estimate
(enter code)
5.4.1
5.4.2
5.5
5.5.1A
5.5.1B
Underground Injection onsite
to Class I Wells
Underground Injection onsite
to Class II-V Wells
Disposal to land onsite
RCRA Subtitle C landfills
Other landfills
5.5.2
5.5.3A
5.5.4
Land treatment/application
farming
RCRA Subtitle C
surface impoundments
Other disposal
SECTION 6. TRANSFERS OF THE TOXIC CHEMICAL IN WASTES TO OFF-SITE LOCATIONS
6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS
(POTWs)
6.1.A Total Quantity Transferred to POTWs and Basis of Estimate
6.1.A.1
Total Transfers
(pounds/year*)
(enter range code ** or estimate)
6.1.A.2 Basis of Estimate
(enter code)
6.1.B
POTW Name
POTW Address
City
State
County
Zip
6.1.B
POTW Name
City
State
County
Zip
If additional pages of Part II, Section 6.1 are attached, indicate the total number of pages
in this box and indicate the Part II, Section 6.1 page number in this box (example: 1,2,3, etc.)
SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS
6.2.
Off-Site EPA Identification Number (RCRA ID No.)
Off-Site Location Name
Off-Site Address
City
State
County
Zip
Is location under control of reporting facility or parent company?
Country
(Non-US)
Yes
No
* For Dioxin or Dioxin-like compounds, report in grams/year
** Range Codes: A=1-10 pounds: B=1-499 pounds; C=500 - 999 pounds.
5.5.3B
Other surface impoundments
POTW Address
Form Approved OMB Number: 2070-0093
(IMPORTANT: Type or print; read instructions before completing form)
Approval Expires: 03/31/2011
Page 4 of 5
FORM R
PART II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)
EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.
TRI Facility ID Number
Toxic Chemical, Category or Generic Name
SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS (CONTINUED)
A. Total Transfers
(pounds/year*)
(enter range code**or estimate)
B. Basis of Estimate
(enter code)
C. Type of Waste Treatment/Disposal/
Recycling/Energy Recovery
(enter code)
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
M
M
M
M
6.2
Off-Site EPA Identification Number (RCRA ID No.)
Off-Site Location Name
Off-Site Address
City
County
Zip
Country
(Non-US)
State
Is location under control of reporting facility or parent company?
Yes
No
A. Total Transfers
(pounds/year*)
(enter range code**or estimate)
B. Basis of Estimate
(enter code)
C. Type of Waste Treatment/Disposal/
Recycling/Energy Recovery
(enter code)
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
M
M
M
M
SECTION 7A. ON-SITE WASTE TREATMENT METHODS AND EFFICIENCY
Not Applicable (NA) -
Check here if no on-site waste treatment is applied to any
waste stream containing the toxic chemical or chemical category.
a. General
Waste Stream
[enter code]
b. Waste Treatment Method(s) Sequence
[enter 3- or 4- character code(s)]
d. Waste Treatment Efficiency
[enter 2 character code]
7A.1a
7A.1b
1
4
7
2
5
8
3
6
7A.1d
7A.2a
7A.2b
3
6
1
4
7
2
5
8
7A.3a
3
6
1
4
7
2
5
8
7A.4a
7A.3b
7A.4b
3
6
1
4
7
2
5
8
7A.5a
7A.5b
3
6
1
4
7
2
5
8
If additional pages of Part II, Section 6.2/7A are attached, indicate the total number of pages in this box
and indicate the Part II, Section 6.2/7 page number in this box:
(example: 1,2,3,etc.)
*For Dioxin or Dioxin-like compounds, report in grams/year
**Range Codes: A=1 - 10 pounds; B=11 - 499 pounds C= 500-999 pounds.
Form Approved OMB Number: 2070-0093
(IMPORTANT: Type or print; read instructions before completing form)
Approval Expires: 03/31/2011
7A.2d
7A.3d
7A.4d
7A.5d
FORM R
PART II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)
EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete. *For Dioxin or Dioxin-like compounds, report in grams/year.
TRI Facility ID Number
Toxic Chemical, Category or Generic Name
Page 5 of 5
SECTION
7B. ON-SITE ENERGY RECOVERY PROCESSES
Not Applicable (NA) -
Check here if no on-site energy recovery is applied to any waste
stream containing the toxic chemical or chemical category.
Energy Recovery Methods [enter 3-character code(s)]
2
3
SECTION 7C. ON-SITE RECYCLING PROCESSES
Not Applicable (NA) -
Check here if no on-site recycling is applied to any waste
stream containing the toxic chemical or chemical category.
Recycling Methods [enter 3-character code(s)]
1
2
3
SECTION 8. SOURCE REDUCTION AND RECYLING ACTIVITIES
Column A
Prior Year
(pounds/year*)
Column B
Current Reporting Year
(pounds/year*)
Column C
Following Year
(pounds/year*)
Column D
Second Following Year
(pounds/year*)
8.1
8.2
Quantity used for energy recovery
onsite
8.3
Quantity used for energy recovery
offsite
8.4
Quantity recycled
onsite
8.5
Quantity recycled offsite
8.6
Quantity treated onsite
8.7
Quantity treated offsite
8.8
Quantity released to the environment as a result of remedial actions, catastrophic events,
or one-time events not associated with production processes (pounds/year)*
8.9
Production ratio or activity index
8.10
Did your facility engage in any source reduction activities for this chemical during the reporting
year? If not, enter “NA” in Section 8.10.1 and answer Section 8.11.
Source Reduction Activities
[enter code(s)]
Methods to Identify Activity (enter codes)
8.10.1
a. b. c.
8.10.2
a. b. c.
8.10.3
a. b. c.
8.10.4
a. b. c.
8.11
Total on-site disposal to Class I
Underground InjectionWells, RCRA
Subtitle C landfills, and other landfills
Total other on-site disposal or other
releases
Total off-site disposal to Class I
Underground Injection Wells, RCRA
Subtitle C landfills, and other landfills
Total other off-site disposal or other
releases
8.1a
8.1b
8.1c
8.1d
1
Form Approved OMB Number: 2070-0093
(IMPORTANT: Type or print; read instructions before completing form)
Approval Expires: 03/31/2011
If you wish to submit additional optional information on source reduction, recycling, or pollution
control activities, check “Yes.”
Yes
| File Type | application/pdf |
| File Title | Form.r.1.7.04 |
| Subject | Form.r.1.7.04 |
| Author | cvail |
| File Modified | 2008-08-27 |
| File Created | 2008-08-27 |