Form 8700-29 Tier One Emergency and Hazardous Chemical Inventory

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

_{Facility Identification}

Tier One

Emergency and Hazardous Chemical Inventory

Aggregate Information by Hazard Type

For Official Use Only

State ID #:

Date Received:

Name Maximum No. of Occupants: ^{ Manned}

 N/A  Unmanned

_{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?}  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 I 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)

I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages 1 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.

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 10 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. 8700-29 OMB Control No. 2050-0072 Page 1 of

Expiration Date: xx/xx/xxxx

_{EPA Form No. 8700-29 OMB Control No. 2050-0072 Page of}

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

		Hazard Max Amount Average Daily Number of Days Type (Range Code) Amount On-Site General Location (Range Code)
Physical Hazard	Fire
	Sudden Release of Pressure
	Reactive
Health Hazard	Immediate (acute)
	Delayed (acute)

_{REPORTING RANGES}

WEIGHT RANGE IN POUNDS
Range Codes	From	To
01	0	99
02	100	499
03	500	999
04	1,000	4,999
05	5,000	9,999
06	10,000	24,999
07	25,000	49,999
08	50,000	74,999
09	75,000	99,999
10	100,000	499,999
11	500,000	999,999
12	1,000,000	9,999,999
13	10,000,000	Greater than 10 million

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