DHS Form 9002 Chemical Security Assessment Tool (CSAT) User and Facili

OMB No. 1670-0007
Expiration Date: May 31, 2011
DEPARTMENT OF HOMELAND SECURITY

Chemical Security Assessment Tool (CSAT)
User and Facility Registration Form
Please read the instructions carefully before completing this form. The instructions must be available during
completion of this form.
Section A: Organization for the Facility
1. Name of Organization

2. Notification Code

Section B: Facility Location Information
3. Name of Facility

4. NAICS Code for the Facility

6b. City

6a. Physical Address

7a. Latitude

6e. County

5. DUNS Identification Code

6c. State

7b. Longitude

6d. Zip Code

8. Additional non-street location information:

Section C: Facility Owner or Operator
9. Facility Owner

10. Facility Operator

Section D: User Information
11. User Role:

Preparer

Submitter

Other
13. CVI Authorized User Number

12. CSAT User Name

14. User Name
14b. Last Name

14a. First Name

14c. Middle Initial

15. User Mailing Address Information
15b. City

15a. Mailing Address

15c. State

15d. Zip Code

16. User Contact Information
16b. Phone Extension

16a. Phone Number

17. Email Address

18. Is the User a U.S. Citizen?

Yes

No

19. Is the User domiciled in the U.S.?

Yes

No

DHS Form 9002 (9/09)

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

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OMB No. 1670-0007
Expiration Date: May 31, 2011

Section E: Authorizer Information
The authorizer verifies that the user account request is valid on behalf of the owner of the facility or company.
20. CSAT User Name

21 CVI Authorized User Number

22. Job Title

23. Authorizer Name
23a. First Name

23c. Middle Initial

23b. Last Name

24. Authorizer Mailing Address Information
25d. Zip Code

25c. State

24b. City

24a. Mailing Address

26. Authorizer Contact Information
26a. Phone Number

26b. Phone Extension

27. Email Address

28. Is the Authorizer a U.S. Citizen?

Yes

No

29. Is the Authorizer an Officer of the Corporation or designated by an Officer of the Corporation?

Yes

No

30. Is the Authorizer domiciled in the U.S.?

Yes

No

Section F: Environmental Protection Agency (EPA) Risk Management Program (RMP) Facility Identifier
31. Does the facility operate under any EPA RMP covered process(es), i.e. Program 1,2,or 3?

Yes

No

32. EPA RMP Facility Identifier

Section G: Co-located Facility
33. Specify the facility's location:
33a. The facility is a host to a co-located tenant facility

33b. The facility is a co-located tenant facility

33c. Not Applicable

If the facility is a host or tenant, enter the name of the host or tenant facility and its corresponding EPA RMP Facility Identifer
34a. Host/ Tenant Facility

34b. Host/ Tenant EPA RMP

Section H: Additional Facility Information
35a. Parent Company 1

DHS Form 9002 (9/09)

35b. Parent Company 1 DUNS

35c. Parent Company 2

35d. Parent Company 2 DUNS

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

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OMB No. 1670-0007
Expiration Date: May 31, 2011

Section I: Signatures
36a. User Name

36b.User Signature

36c. Date

37a. Authorizer Name

37b. Authorizer Signature

37c. Date

38a. Authorizer CSAT User Name

38b. Authorizer CVI User Number

38c. Date

DHS Form 9002 (9/09)

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

3

OMB No. 1670-0007
Expiration Date: May 31, 2011

PRIVACY ACT STATEMENT
1.

Authority: Section 550 (c) of Public Law 109-295 and implementing regulations, 6 CFR Part 27.

2.

Purpose: DHS will use the information provided in this form to register a new CSAT user and a facility.

3.

Routine Uses: The Personal Identifiable Information (PII) will be used by and disclosed pursuant to a published Privacy
Act System of Records Notice. CFATS PII is collected under the General Information Technology Access Account
Records System (GITAARS) http://edocket.access.gpo.gov/2008/E8-10895.htm DHS/ALL-004

4.

Disclosure: Furnishing this information is required pursuant to Section 550 (c) of Public Law 109-295 and
implementing regulations, 6 CFR Part 27.

PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act, no one is required to respond to a collection of information unless it
displays a valid OMB Control Number. The valid OMB Control Number for this information collection is 1670-0007.

INSTRUCTIONS
The instructions for completing this form can be found in the CSAT User Registration User Guide. The User Guide is
available at www.dhs.gov/chemicalsecurity.

DHS Form 9002 (9/09)

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

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