OMB Control No. 2050-0072

+--------------+---------------------+---+------+-----------------------+
| **Tier One** | EMERGENCY AND       |   | FOR  | ID#                   |
|              | HAZARDOUS CHEMICAL  |   | OFFI |                       |
|              | INVENTORY           |   | CIAL |                       |
|              |                     |   | USE  |                       |
|              | *Aggregate          |   | ONLY |                       |
|              | Information by      |   |      |                       |
|              | Hazard Type*        |   |      |                       |
+--------------+---------------------+---+------+-----------------------+
|              |                     |   |      | Date Received         |
+--------------+---------------------+---+------+-----------------------+

*Important: Read instructions before completing form* Reporting Period
From January 1 to December 31, 20 ­­­­­­­­­­\_\_ ­­­­­­­­

+-------------------------------------------+---+-------------------------+
| **Facility Identification**               |   | **Emergency Contacts**  |
+-------------------------------------------+---+-------------------------+
| Name                                      |   | Name                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      |   | \_\_\_\_\_\_\_\_\_\_    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | \_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   | _\_\_\_\_\_\_\_\_\_\_\_ |
|                                           |   |                         |
| Street                                    |   | Title                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |   | \_\_\_\_\_\_\_\_\_\_\_  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | \_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   | _\_\_\_\_\_\_\_\_\_\_\_ |
|                                           |   |                         |
| City County State Zip \_\_\_\_\_\_\_\_\_  |   | Phone (­­­\_\_\_\_\_)      |
|                                           |   | \_\_\_                  |
| NAICS Code                                |   | \_\_\_\_\_\_\_\_\_\_\_\ |
|                                           |   | _\_\_\_\_\_\_\_\_\_\_\_ |
| Dun & Brad Number                         |   |                         |
|                                           |   | 24 hour Phone           |
|                                           |   | (\_\_\_\_\_)            |
|                                           |   | \_\_\_\_\_\_\_\         |
|                                           |   | _\_\_\_\_\_\_\_\_\_\_\_ |
+-------------------------------------------+---+-------------------------+
| **Owner/Operator**                        |   | Name                    |
|                                           |   | \_\_\_\_\_\_\_\_\_\_    |
|                                           |   | \_\_\_\_\_\_\_\_\_\_\_\ |
|                                           |   | _\_\_\_\_\_\_\_\_\_\_\_ |
|                                           |   |                         |
|                                           |   | Title                   |
|                                           |   | \_\_\_\_\_\_\_\_\_\_\_  |
|                                           |   | \_\_\_\_\_\_\_\_\_\_\_\ |
|                                           |   | _\_\_\_\_\_\_\_\_\_\_\_ |
|                                           |   |                         |
|                                           |   | Phone (­­­\_\_\_\_\_)      |
|                                           |   | \_\_\_                  |
|                                           |   | \_\_\_\_\_\_\_\_\_\_\_\ |
|                                           |   | _\_\_\_\_\_\_\_\_\_\_\_ |
|                                           |   |                         |
|                                           |   | 24 hour Phone           |
|                                           |   | (\_\_\_\_\_)            |
|                                           |   | \_\_\_\_\_\_\_\         |
|                                           |   | _\_\_\_\_\_\_\_\_\_\_\_ |
+-------------------------------------------+---+-------------------------+
| Name                                      |   |                         |
| ­­­­­­­­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |   |                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   |                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                         |
|                                           |   |                         |
| Mail Address                              |   |                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_              |   |                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   |                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                         |
|                                           |   |                         |
| Phone                                     |   |                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_                |   |                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   |                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                         |
+-------------------------------------------+---+-------------------------+

  -- -- -------------------------------------------------------------------
        

        Check if information below is identical to the information
        submitted last year.

        
  -- -- -------------------------------------------------------------------

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 34%" />
<col style="width: 1%" />
<col style="width: 21%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="3"></td>
<td rowspan="3"><em>Hazard Type</em></td>
<td colspan="4" rowspan="3"><em>Max Amount</em></td>
<td colspan="3" rowspan="3"></td>
<td colspan="4" rowspan="3"><em>Average Daily Amount</em></td>
<td colspan="2" rowspan="3"></td>
<td colspan="3" rowspan="3"><em>Number of Days On-Site</em></td>
<td colspan="2" rowspan="3"></td>
<td rowspan="3"><em>General Location</em></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>Check if site plan is attached</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="7"><blockquote>
<p><strong>Physical Hazards</strong></p>
</blockquote></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="3" rowspan="7"></td>
</tr>
<tr class="odd">
<td>Fire</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>Sudden Release</p>
<p>of Pressure</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>Reactivity</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td rowspan="5"><strong>Health Hazards</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="3" rowspan="5"></td>
</tr>
<tr class="even">
<td colspan="2"><p>Immediate</p>
<p>(acute)</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><p>Delayed</p>
<p>(acute)</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
</tbody>
</table>

+-----------------------------------+-----------------------------------+
| **Certification** *(Read and sign | \* Reporting Ranges               |
| after completing all sections)*   |                                   |
|                                   | Range Weight Range in pounds      |
|                                   |                                   |
|                                   | Code From\..... To\...\...        |
+-----------------------------------+-----------------------------------+
| I certify under penalty of law    | 01 0 99                           |
| that I have personally examined   |                                   |
| and am familiar with the          | 02 100 999                        |
| information submitted in pages    |                                   |
| one through , and that based on   | 03 1000 9,999                     |
| my inquiry of those individuals   |                                   |
| responsible for obtaining the     | 04 10,000 99,999                  |
| information, I believe that the   |                                   |
| submitted information is true,    | 05 100,000 999,999                |
| accurate and complete.            |                                   |
|                                   | 06 1,000,000 9,999,999            |
| [­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\      |                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | 07 10,000,000 49,999,999          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | 08 50,000,000 99,999,999          |
| \_\_\_\_\_\_\_\_\_\_]{.underline} |                                   |
|                                   | 09 100,000,000 499,999,999        |
| Name and official title of        |                                   |
| owner/operator OR                 | 10 500,000,000 999,999,999        |
| owner/operator's authorized       |                                   |
| representative                    | 11 1 billion Higher than 1        |
|                                   | billion                           |
| [­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\      |                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
| \_\_\_\_\_\_\_\_\_\_]{.underline} |                                   |
|                                   |                                   |
| Signature Date Signed             |                                   |
+-----------------------------------+-----------------------------------+

**EPA Form 8700-29**