8700-30 Tier II Form

_{ 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