Form 8700-30 Tier II Form

Community Right-to-Know Reporting Requirements Under Sections 311 and 312 of the Emergency Planning and Community Right-to-Know Act (EPCRA) (Renewal)

Tier II Form Ver. 3-2019

Community Right-to-Know Reporting Requirements Under Sections 311 and 312 of EPCRA - Private Sector

OMB: 2050-0072

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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



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.



Name and official title of owner/operator OR owner/operator’s authorized representative



Signature Date Signed

Range Code 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

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050-0072). Responses to this collection of information are mandatory (40 CFR 370.42). An agency may not conduct or sponsor, and a person is not required to, respond to a collection of information unless it displays a currently valid OMB control number. 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, Regulatory Support 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 Expiration Date: xx/xx/xxxx

Page 1 of

EPA Form No. 8700-30 OMB Control No. 2050-0072 Page of

Chemical Description

Physical Hazards

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


Explosive

Flammable (gases, aerosols, liquids, or solids)

Oxidizer (liquid, solid or gas)

Self-reactive

Pyrophoric (liquid or solid)

Pyrophoric Gas

Self-heating

Organic peroxide

Corrosive to metal

Gas under pressure (compressed gas)

In contact with water emits flammable gas

Combustible Dust

Hazard Not Otherwise
Classified



Acute toxicity (any route of exposure)

Skin corrosion or irritation

Serious eye damage or eye irritation

Respiratory or skin
sensitization

Germ cell mutagenicity

Carcinogenicity

Reproductive toxicity

Specific target organ toxicity(single or repeated exposure)

Aspiration hazard

Simple Asphyxiant

Hazard Not Otherwise
Classified



Maximum Amount

Range Code:




Confidential:

Yes No


Below Reporting
Thresholds (optional)



State
or Local

Requirements


Average Daily

Amount

Range 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


Explosive

Flammable (gases, aerosols, liquids, or solids)

Oxidizer (liquid, solid or gas)

Self-reactive

Pyrophoric (liquid or solid)

Pyrophoric Gas

Self-heating

Organic peroxide

Corrosive to metal

Gas under pressure (compressed gas)

In contact with water emits flammable gas

Combustible Dust

Hazard Not Otherwise
Classified



Acute toxicity (any route of exposure)

Skin corrosion or irritation

Serious eye damage or eye irritation

Respiratory or skin
sensitization

Germ cell mutagenicity

Carcinogenicity

Reproductive toxicity

Specific target organ toxicity(single or repeated exposure)

Aspiration hazard

Simple Asphyxiant

Hazard Not Otherwise
Classified



Maximum Amount (Total Mixture) Range Code:




Confidential:

Yes No


Below Reporting Thresholds (optional)



State
or Local

Requirements


Average Daily Amount (Total Mixture) Range Code:


EHS(s) Name (if applicable):




CAS No.


No. of days on site:


Maximum Amount of each EHS in the Mixture

Range 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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