Form 9350-2 Form A

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Page 1 of 2

DRAFT

T OXICS RELEASE INVENTORY FORM A

Complete form online via TRI-MEweb. For a trade secretion submission, send completed forms to TRI Reporting Center, P. O. Box 10163, Fairfax, VA 22038. The annual public burden related to the Form A is estimated to average 21.96 hours per response for a facility filing a report on one chemical. See the Reporting Forms and Instructions for more information on submissions and the Paperwork Reduction Act.

TRI Facility ID Number

This section only applies if you are revising or withdrawing a previously submitted form, otherwise leave blank.

Revision (Enter up to two code(s))

Withdrawal (Enter up to two code(s))

IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.

PART I. FACILITY IDENTIFICATION INFORMATION

SECTION 1. REPORTING YEAR

SECTION 2. TRADE SECRET INFORMATION

2.1

Are you claiming the toxic chemical identified on page 2 as a trade secret?

2.2

Yes (Answer question 2.2; attach substantiation forms)

No (Do not answer 2.2; go to Section 3)

Is this copy

Sanitized

Unsanitized

(Answer only if “Yes” in 2.1)

SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)

I hereby certify that to the best of my knowledge and belief, for each toxic chemical listed in this statement, the annual reportable amount as defined in 40 CFR 372.27(a), did not exceed 500 pounds for this reporting year and that the chemical was manufactured, processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year.

Name and official title of owner/operator or senior management official:

Signature:

Date signed:

SECTION 4. FACILITY IDENTIFICATION

4.1

Facility or Establishment Name

TRI Facility ID Number

BIA Code

Physical Street Address

Mailing Address (if different from physical street address)

City/County/State/ZIP Code

City/State/ZIP Code

Country (Non-US)

4.2

This report contains information for: (Important: Check c or d if applicable)

c.

A Federal Facility

d. d.

GOCO

4.3

Technical Contact Name

Telephone Number (include area code and ext.)

Email Address

4.4

Public Contact Name

Telephone Number (include area code and ext.)

Email Address

4.5

NAICS Code(s) (6 digits)

Primary

b.

c.

d.

e.

f.

a.

4.6

Dun & Bradstreet Number(s) (9 digits)

a.

b.

SECTION 5. PARENT COMPANY INFORMATION

5.1

Name of U.S. Parent Company (for TRI Reporting purposes)

No U.S. Parent Company

(for TRI Reporting purposes)

5.2

Parent Company’s Dun & Bradstreet Number

NA

EPA Form 9350 -2 (Rev. 10/2018). Previous editions are obsolete.

EPA FORM A PART II. CHEMICAL IDENTIFICATION Do not use this form for reporting PBT chemicals, including Dioxin and Dioxin-like Compounds*				TRI Facility ID Number
SECTION 1. TOXIC CHEMICAL IDENTITY Report of
1.1		CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)
1.2		Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
1.3		Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)
SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)
2.1	Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)
Section 9.2. Optional Pollution Prevention and Additional Information for THIS Toxic Chemical
9.2			If you wish to provide optional chemical specific pollution prevention or additional information, provide it here.
SECTION 1. TOXIC CHEMICAL IDENTITY Report of
1.1		CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)
1.2		Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
1.3		Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)
SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)
2.1	Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)
Section 9.2. Optional Pollution Prevention and Additional Information for THIS Toxic Chemical
9.2			If you wish to provide optional chemical specific pollution prevention or additional information, provide it here.

*See the TRI Reporting Forms and Instructions manual for the list of PBT Chemicals (including Dioxin and Dioxin-like Compounds)

EPA Form 9350 -2 (Rev. 10/2018). Previous editions are obsolete. (Make additional copies of this page, if needed)