9350-1 Form R TRI

Paperwork Reduction Act Notice: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-0212). Responses to this collection of information are mandatory (40 CFR 372). 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 21 hours, 57 minutes to 35 hours, 42 minutes 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
to the Regulatory Support Division Director, 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.

Section 4.1-4.2:

Section 4.3-4.4:

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Section 4.5-4.6

Section 5: Parent Company

Part II: Section 3.1-3.3

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Part II: Section 1

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Part II Section 2.1 Mixtures

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Part II Section 4.1

Part II Section 5.1-5.2 Point and Non-point Emissions

Part II Section 5.3: Water Bodies

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Part II Section 5.4-5.5 Land Releases

Part II Section 5.5 Waste Rock

Part II Section 6.1 POTW Releases

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Part II Section 6.2 Off-site Transfer Locations

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Part II Section 7.a On-site Waste Treatment

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Part II Section 7.b Onsite Energy Recovery

Part II Section 7.c Onsite Recycling

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Part II: Section 8.8 Non-Production Quantities

Part II: Section 8.1-8.7 Waste Management

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Part II: Section 8.9 Production or Activity Ratio

Part II: Section 8.10 Source Reduction

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Part II: Section 8.11 Pollution Prevention

Part II: Section 9.1 Miscellaneous Information

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Certifying Official Signature:

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Revision or Withdrawal Codes:

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Form A
Changing TRI Form R or A

TRI-MEweb Screenshots

Section 4.1-4.2: Facility Identification

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Section 4.3-4.4: Contact Info

Section 4.5-4.6 Dun and Bradstreet

Section 5: Parent Company

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Part II: Section 1.1-1.3 Toxic Chemical Identity

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Part II Section 2.1 Mixtures

Part II Section 9.2

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Certifying Official Signature:

Form R Schedule 1 (Dioxin releases)
Section 5: Onsite Releases and Disposal

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The following Section may have a schedule 1 form
Section 5.1
Section 5.2
Section 5.3
Section 5.4.1
Section 5.4.2
Section 5.5

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Section 5: Congener Page
Page 1 and 2 of 4

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Section 6.1: POTW
Page 3 of 4 of Schedule 1 form

Section 6.2: Off-site transfer
Page 3 of 4 of Schedule 1 form

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Section 8.1-8.7 Waste Management
Page 4 of 4

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