8700-30 Tier II Confidential Form

 Check if information below is identical to the information submitted last year. Reporting Period: January 1 to December 31, 20____

Confidential Location Information Sheet Tier Two Emergency and Hazardous Chemical Inventory Specific Information by Chemical

For Official Use Only State ID#: Date Received

Facility Identification

Name

Maximum No. of Occupants:

 Manned Unmanned

 N/A

Street

County

City

State

Zip

Latitude

Longitude

NAICS Code Phone Number (optional)

Dun & Bradstreet Number

TRI Facility ID:

RMP Facility ID:

 N/A

 N/A

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

Owner or Operator Information

Parent Company Information (optional)

Name

Name

Dun & Bradstreet Number:

Address

Address

Phone Number

Email

Phone Number

Email

( )

( )

Facility Emergency Coordinator (if applicable)

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

Certification (Read and sign after completing all sections)

Reporting Ranges Weight Range in pounds

Range Code

From

To

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

The public reporting and recordkeeping burden for this collection of information is estimated to range from 6 to 120 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA Form No. 8700-30

OMB Control No. 2050-0072

Page 1 of ___

EPA Form No. 8700-30

OMB Control No. 2050-0072

Page __ of ___

Chemical Description

Physical and Health Hazards

Inventory

Type of Storage

Storage Conditions (Pressure, Temperature)

Storage Locations

Additional Reporting Information (Optional)

 Check if information below is identical to the information submitted last year. Chemical Name: CAS No. EHS: Yes  No   Solid  Liquid  Gas  Trade Secret

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

Maximum Amount Code:

Confidential:  Yes  No

 Below Reporting Thresholds (optional)  State or Local Requirements

Average Daily Amount Code:

No. of days on site:

 Check if information below is identical to the information submitted last year. Mixture or Product Name: CAS No.  Not Available  Solid  Liquid  Gas  Trade Secret EHS: Yes  No 

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

Maximum Amount (Total Mixture) Code:

Confidential:  Yes  No

 Below Reporting Thresholds (optional)  State or Local Requirements

Average Daily Amount (Total Mixture) Code:

EHS(s) Name (if applicable):

No. of days on site:

CAS No.

Maximum Amount of EHS in the Mixture Code:

Non-EHS(s) Name (optional):

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