Form 9350-1 TRI Form R

DRAFT

Form Approved OMB Number: 2025-0009

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2014 Page 17 of 6

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

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

WHERE TO SEND COMPLETED FORMS:

1. TRI Data Processing Center

P. O. Box 10163

Fairfax, VA 22038

2. APPROPRIATE STATE OFFICE

(See instructions in Appendix E)

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

Revision (Enter up to two code(s))

Withdrawal (Enter up to two code(s))

IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.

PART I. FACILITY IDENTIFICATION INFORMATION

SECTION 1. REPORTING YEAR ________

SECTION 2. TRADE SECRET INFORMATION

2.1

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

2.2

Is this copy Sanitized Unsanitized

(Answer only if “Yes” in 2.1)

Yes (Answer question 2.2;
attach substantiation forms)

No (Do not answer 2.2;
go to Section 3)

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

Facility or Establishment Name

TRI Facility ID Number

Physical Street Address

Mailing Address (if different from physical street address)

City/County/State/ZIP Code

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)

a.

An entire facility

b.

Part of a facility

c.

A federal
facility

d.

GOCO

4.3

Technical Contact Name

Telephone Number (include area code)

Email Address

4.4

Public Contact Name

Telephone Number (include area code)

Email Address

4.5

NAICS Code(s)
(6 digits)

Primary

a.

b.

c.

d.

e.

f.

4.6

Dun & Bradstreet Number(s) (9 digits)

a.

b.

SECTION 5. Parent Company Information

5.1

Name of U.S. Parent Company

(for TRI Reporting purposes)

No U.S. Parent Company

(for TRI Reporting purposes)

5.2

Parent Company’s Dun & Bradstreet Number

NA

EPA form 9350 -1 (Rev. 07/2011) – Previous editions are obsolete.

FORM R Part II. CHEMICAL-SPECIFIC INFORMATION

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 1. TOXIC CHEMICAL IDENTITY (Important: DO NOT complete this section if you are reporting a mixture component in Section 2 below.)

1.1

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 I, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1.)

2.1

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

SECTION 3. ACTIVITIES AND USES OF THE TOXIC CHEMICAL AT THE FACILITY (Important: Check all that apply.)

3.1

Manufacture the toxic chemical:

3.2

Process the toxic chemical:

3.3

Otherwise use the toxic chemical:

a.  Produce b.  Import

a.  As a reactant b.  As a formulation component c.  As an article component d.  Repackaging e.  As an impurity

a.  As a chemical processing aid b.  As a manufacturing aid c.  Ancillary or other use

If Produce or Import c.  For on-site use/processing d.  For sale/distribution e.  As a byproduct f.  As an impurity

SECTION 4. MAXIMUM AMOUNT OF THE TOXIC CHEMICAL ON-SITE AT ANY TIME DURING THE CALENDAR YEAR

4.1

(Enter two digit code from instruction package.)

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE

A. Total Release (pounds/year*) (Enter a range code** or estimate)

B. Basis of Estimate (Enter code)

C. Percent 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)

NA 

Stream or Water Body Name

5.3.1

5.3.2

5.3.3

I f additional pages of Part II, Section 5.3 are attached, indicate the total number of pages in this box a nd indicate the Part II, Section 5.3 page number in this box. (Example: 1, 2, 3, etc.)

EPA form 9350 -1 (Rev. 07/2011) – Previous editions are obsolete. *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)

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE (continued)

NA

A. Total Release (pounds/year*) (Enter a range code** or estimate)

B. Basis of Estimate (Enter code)

5.4.1

Underground Injection on-site to Class I Wells



5.4.2

Underground Injection on-site to Class II-V Wells



5.5

Disposal to land on-site

5.5.1A

RCRA Subtitle C landfills



5.5.1B

Other landfills



5.5.2

Land treatment/application farming



5.5.3A

RCRA Subtitle C surface impoundments



5.5.3B

Other surface impoundments



5.5.4

Other disposal



SECTION 6. TRANSFER(S) OF THE TOXIC CHEMICAL IN WASTES TO OFF-SITE LOCATIONS

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs) NA 

6.1.B._

POTW Name

POTW Address

City

County

State

ZIP

A. Quantity Transferred to this POTW (pounds/year*) (Enter range code**or estimate)

B. Basis of Estimate (Enter code)

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.)

6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS NA 

6.2.___ Off-Site EPA Identification Number (RCRA ID No.)

Off-Site Location Name:

Off-Site Address:

City

County

State

ZIP

Country (non-US)

Is this location under control of reporting facility or parent company?  Yes  No

EPA form 9350 -1 (Rev. 07/2011) – Previous editions are obsolete. *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)																			TRI Facility ID Number
																			Toxic Chemical, Category, or Generic Name
6.2. TRANSFERS TO OTHER OFF-SITE LOCATION (CONTINUED)
A. Total Transfer (pounds/year*) (Enter a range code** or estimate)							B. Basis of Estimate (Enter code)										C. Type of Waste Treatment/Disposal/ Recycling/Energy Recovery (Enter code)
1.							1.										1. M
2.							2.										2. M
3.							3.										3. M
4.							4.										4. M
6.2____ Off-Site EPA Identification Number (RCRA ID No.)
Off-Site Location Name:
Off-Site Address:
City							County					State				ZIP				Country (non-US)
Is this location under control of reporting facility or parent company? Yes  No 
A. Total Transfer (pounds/year*) (Enter a range code** or estimate)							B. Basis of Estimate (Enter code)										C. Type of Waste Treatment/Disposal/ Recycling/Energy Recovery (Enter code)
1.							1.										1. M
2.							2.										2. M
3.							3.										3. M
4.							4.										4. M
SECTION 7A. ON-SITE WASTE TREATMENT METHODS AND EFFICIENCY
 Not Applicable (NA) - Check here if no on-site waste treatment method 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))																	c. Waste Treatment Efficiency (Enter 2 character code)
7A.1a				7A.1b				1						2 5 8							7A.1c
				3				4 7
				6
7A.2a				7A.2b				1 4						2							7A.2c
				3										5 8
				6				7
7A.3a				7A.3b				1 4 7						2							7A.3c
				3 6										5 8
7A.4a				7A.4b				1 4 7						2 5 8							7A.4c
				3 6
7A.5a				7A.5b				1 4 7						2 5 8							7A.5c
				3 6
If additional pages of Part II, Section 6.2/7.A are attached, indicate the total number of pages in this box a nd indicate the Part II, Section 6.2/7.A page number in this box. (Example: 1, 2, 3, etc.)

EPA form 9350 -1 (Rev. 07/2011) – Previous editions are obsolete. *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

TRI Facility ID Number

Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

Toxic Chemical, Category, or Generic Name

SECTION 7B. ON-SITE ENERGY RECOVERY PROCESSES

 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))

1

2

3

SECTION 7C. ON-SITE RECYLING PROCESSES

 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. DISPOSAL OR OTHER RELEASES, SOURCE REDUCTION, AND RECYCLING 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

8.1a

Total on-site disposal to Class I Underground Injection Wells, RCRA Subtitle C landfills, and other landfills

8.1b

Total other on-site disposal or other releases

8.1c

Total off-site disposal to Class I Underground Injection Wells, RCRA Subtitle C landfills, and other landfills

8.1d

Total other off-site disposal or other releases

8.2

Quantity used for energy recovery on-site

8.3

Quantity used for energy recovery off-site

8.4

Quantity recycled on-site

8.5

Quantity recycled off-site

8.6

Quantity treated on-site

8.7

Quantity treated off-site

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 newly implemented source reduction activities for this chemical during the reporting year? If so, complete the following section; if not, check NA. NA 

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.

EPA form 9350 -1 (Rev. 07/2011) – Previous editions are obsolete. *For Dioxin or Dioxin-like compounds, report in grams/year.

FORM R		TRI Facility ID Number
Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)		Toxic Chemical, Category, or Generic Name
SECTION 8.11. DISPOSAL OR OTHER RELEASES, SOURCE REDUCTION, AND RECYCLING ACTIVITIES
8.11	If you wish to submit additional optional information on source reduction, recycling, or pollution control activities, provide it here.
SECTION 9. MISCELLANEOUS INFORMATION
9.1	If you wish to submit any miscellaneous, additional, or optional information regarding your Form R submission, provide it here.

EPA form 9350 -1 (Rev. 07/2011) – Previous editions are obsolete.