8700-30 Tier Two Emergency and Hazardous Chemical Inventory

Revisions to the Emergency and Hazardous Chemical Inventory Forms (Tier I and Tier II), Section 312 of the Emergency Planning and Community Right-to-Know Act (EPCRA) (Proposed Rule)

2436supp01 - Tier II Inventory Form PROPOSED 04 28 11

State Agencies

OMB: 2050-0206

Document [doc]
Download: doc | pdf

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


Page ___ of ___



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File Modified2011-05-27
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