9350-3 Schedule 1

DRAFT (IMPORTANT: Read instructions before completing form; type or use fill-and-print form)										Form Approved OMB Number: 2025-0009 Approval Expires: 07/31/2014								Page 1 of 4
United States Environmental Protection Agency			FORM R Schedule 1												TRI Facility ID Number
			PART II. CHEMICAL-SPECIFIC INFORMATION (continued)
SECTION 5. QUANTITY OF DIOXIN AND DIOXIN-LIKE COMPOUNDS ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE
		5.1		NA		5.2	NA				5.3	Discharges to receiving streams or water bodies (Enter data for one stream or water body per box)					NA
		Fugitive or non- point air emissions				Stack or point air emissions					5.3.1			5.3.2		5.3.3
D. Mass (grams) of each compound in the category (1-17)	1
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If additional pages of Section 5.3 are attached, indicate the total number of pages in this box
and indicate the Section 5.3 page number in this box										(Example: 1, 2, 3, etc.)

DRAFT (IMPORTANT: Read instructions before completing form; type or use fill-and-print form)													Form Approved OMB Number: 2025-0009 Approval Expires: 07/31/2014														Page 2 of 4
	FORM R Schedule 1																						TRI Facility ID Number
	PART II. CHEMICAL-SPECIFIC INFORMATION (continued)
SECTION 5. QUANTITY OF DIOXIN AND DIOXIN-LIKE COMPOUNDS ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE
			Underground Injection						5.5 Disposal to land on-site
			5.4.1	NA		5.4.2	NA		5.5.1A	NA		5.5.1B		NA		5.5.2	NA		5.5.3A	NA		5.5.3B		NA		5.5.4		NA
			Underground Injection on-site to Class I Wells			Underground Injection on-site to Class II-V Wells			RCRA Subtitle C landfills			Other landfills				Land treatment/ application farming			RCRA Subtitle C surface impoundments			Other surface impoundments				Other disposal
C. Mass (grams) of each compound in the category (1-17)		1
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DRAFT (IMPORTANT: Read instructions before completing form; type or use fill-and-print form)																				Form Approved OMB Number: 2025-0009 Approval Expires: 07/31/2014															Page 3 of 4
FORM R Schedule 1 PART II. CHEMICAL-SPECIFIC INFORMATION (continued)																														TRI Facility ID Number
SECTION 6. TRANSFERS OF DIOXIN AND DIOXIN-LIKE COMPOUNDS IN WASTES TO OFF-SITE LOCATIONS
6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs) NA
6.1.A.3 Mass (grams) of each compound in the category (1-17)
1			2				3				4					5					6					7						8				9
10			11				12				13					14					15					16						17
6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS NA
6.2.__				D. Mass (grams) of each compound in the category (1-17)
1.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
2.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
3.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
4.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
6.2.__				D. Mass (grams) of each compound in the category (1-17)
1.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
2.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
3.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
4.				1				2				3			4							5					6				7						8
9				10				11				12			13							14					15				16						17
If additional pages of Section 6.1 or 6.2 are attached, indicate the total number of pages in this box
and indicate the Section 6.1 or 6.2 page number in this box																			(Example: 1, 2, 3, etc.)

DRAFT (IMPORTANT: Read instructions before completing form; type or use fill-and-print form)											Form Approved OMB Number: 2025-0009 Approval Expires: 07/31/2014												Page 4 of 4
FORM R Schedule 1 PART II. CHEMICAL-SPECIFIC INFORMATION (continued)																				TRI Facility ID Number
SECTION 8. DISPOSAL OR OTHER RELEASES, SOURCE REDUCTION, AND RECYCLING ACTIVITIES FOR DIOXIN AND DIOXIN-LIKE COMPOUNDS (current year only)
		8.1a		8.1b		8.1c		8.1d		8.2			8.3		8.4		8.5		8.6			8.7			8.8
		Total on-site disposal to Class 1 Underground Injection Wells, RCRA Subtitle C landfills, and other landfills		Total other on-site disposal or other releases		Total off-site disposal to Class 1 Underground Injection Wells, RCRA Subtitle C landfills, and other landfills		Total other off-site disposal or other releases		Quantity used for energy recovery on-site			Quantity used for energy recovery off-site		Quantity recycled on-site		Quantity recycled off-site		Quantity treated on-site			Quantity treated off-site			Quantity released to the environment as a result of remedial actions, catastrophic events, or one-time events not associated with production processes
Column f. Mass (grams) of each compound in the category (1-17)	1
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EPA Form 9350-3