8700-29 Tier I Inventory Form

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

Tier One Emergency and Hazardous Chemical Inventory Aggregate Information by Hazard Type

For Official Use Only State ID #: Date Received:

Facility Identification

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 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. 8700-29

OMB Control No. 2050-0072

Page 1 of ----

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 Type	Max Amount	Average Daily Amount		Number of Days On-Site	General Location
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