8700-30 Tier II Inventory Form

Hazardous Chemical Reporting: Emergency and Hazardous Chemical Inventory Forms (Tier I and Tier II) (Renewal)

Tier II Inventory Form

Private Facilities

OMB: 2050-0206

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

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

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AuthorMelissa Romero
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File Created2021-01-24

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