 Check if information below is identical to the information submitted last year. Reporting Period: January 1 to December 31, 20____

Tier One 

Emergency and Hazardous Chemical Inventory

Aggregate Information by Hazard Type 

For Official Use Only 

State ID #: 

Date Received: 

Facility Identification 

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 

The	public	reporting	and	recordkeeping	burden	for	this	collection	of	information	is	estimated	to	range	from	6	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,	Collection	Strategies	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. 8700-29 OMB Control No. 2050-0072 Page 1 of ___
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 

Type 

Max Amount 

(Range Code)

Average Daily 

Amount 

(Range Code)

Number of Days 

On-Site General Location 

Physical Hazard 

Fire 

Sudden 

Release of 

Pressure 

 

Reactive 

Health Hazard Immediate 

(acute) 

Delayed 

(acute) 

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