8700-29 Tier I Form

_{ 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

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 370.41). 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 this formation, 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 (2821T), 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 of}

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

Hazard Types		Max Amount (Range Code)	Average Daily Amount (Range Code)	Number of Days On-Site	General Location
Physical Hazard	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
Health Hazard	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

_{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