8700-30 Tier Two Emergency and Hazardous Chemical Inventory

 Check if information below is identical to the information submitted last year.

Tier Two Emergency and Hazardous Chemical Inventory Specific Information by Chemical Reporting Period: January 1 to December 31, 20____

Facility Identification

Name

TRI Facility ID

RMP Facility ID

Street

County

City

State

Zip

Phone Number

( )

Latitude

Longitude

NAICS Code

Dun & Brad Number

FTE

Owner or Operator

Parent Company

Name

Name

Dun & Brad Number

Address

Address

Phone Number

Email

Phone Number

Email

( )

( )

Facility Emergency Coordinator

Tier II Information Contact

Name

Title

Name

Title

Email Address

Email Address

Phone Number

24-hour Phone

Phone Number

( )

( )

( )

Emergency Contacts

Name

Name

Title

Title

Phone Number

24-hour Phone

Phone Number

24-hour Phone

( )

( )

( )

( )

Email Address

Email Address

Subject to Emergency Planning under Section 302 of EPCRA (40 CFR part 355)?

 Yes

 No

Subject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68, Risk Management Program)?

 Yes

 No

Certification (Read and sign after completing all sections)

Reporting Ranges Weight Range in pounds

Range Code

To

From

I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through , and that based on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate and complete.

01 02 03 04 05 06 07 08 09 10 11 12 13

0 100 500 1,000 5,000 10,000 25,000 50,000 75,000 100,000 500,000 1,000,000 10,000,000

99 499 999 4,999 9,999 24,999 49,999 74,999 99,999 499,999 999,999 9,999,999 Greater than 10 million

Name and official title of owner/operator OR owner/operator’s authorized representative

Signature

Date Signed

Optional Attachments:  I have attached a site plan  I have attached a list of site coordinate abbreviations  I have attached a description of dikes and other safeguard measures

EPA Form No. 8700-30

OMB Control No. 2050-0072

Page 1 of ___

Chemical Description

Physical and Health Hazards

Inventory

Type of Storage

Storage Conditions (Pressure, Temperature)

Storage Locations

Chemical Name: EHS Yes  No  CAS No.  Solid  Liquid  Gas  Trade Secret

Fire Sudden Release of Pressure Reactivity Immediate (Acute) Delayed (Chronic)

Maximum Daily Code:

Average Daily Code:

No. of days on site:

Chemical Name: EHS Yes  No  CAS No.  Solid  Liquid  Gas  Trade Secret

Fire Sudden Release of Pressure Reactivity Immediate (Acute) Delayed (Chronic)

Maximum Daily Code:

Average Daily Code:

No. of days on site:

Mixture Name:  Solid  Liquid  Gas  Trade Secret

Fire Sudden Release of Pressure Reactivity Immediate (Acute) Delayed (Chronic)

Maximum Daily (Total Mixture) Code:

Average Daily (Total Mixture) Code:

EHS(s) Name:

Maximum Daily (EHS) Code:

Non-EHS(s) Name:

Average Daily (EHS) Code:

 Solid  Liquid  Gas  Trade Secret

No. of days on site:

Mixture Name:  Solid  Liquid  Gas  Trade Secret

Fire Sudden Release of Pressure Reactivity Immediate (Acute) Delayed (Chronic)

Maximum Daily (Total Mixture) Code:

Average Daily (Total Mixture) Code:

EHS(s) Name:

Maximum Daily (EHS) Code:

Non-EHS(s) Name:

Average Daily (EHS) Code:

 Solid  Liquid  Gas  Trade Secret

No. of days on site:

EPA Form No. 8700-30

OMB Control No. 2050-0072

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