DHS Form 9002.3 Chemical Security Assessment Tool (CSAT) Facility Inform

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

Chemical Security Assessment Tool (CSAT)
Facility Information Change Request
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

6e. County

7a. Latitude

7b. Longitude

5. DUNS Identification Code

6c. State

6d. Zip Code

8. Additional non-street location information:

Section C: Facility Owner or Operator
9. Facility Owner

10. Facility Operator

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

Yes

No

12. EPA RMP Facility Identifier

Section E: Co-located Facility
13. Specify the facility's location:
13a. The facility is a host to a co-located tenant facility

13b. The facility is a co-located tenant facility

13c. 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
14a. Host/ Tenant Facility

14b. Host/ Tenant EPA RMP

Section F: Additional Facility Information
15a. Parent Company 1

DHS Form 9002.3 (9/09)

15b. Parent Company 1 DUNS

15c. Parent Company 2

15d. 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 G: Signatures
16a. User Name

16b.User Signature

16c. Date

17a. Authorizer Name

17b. Authorizer Signature

17c. Date

18a. Authorizer CSAT User Name

18b. Authorizer CVI User Number

18c. Date

DHS Form 9002.3 (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

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 updated previously submitted facility
information.

3.

Routine Uses: The Personal Identifiable Information 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 9002.3 (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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