###  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 Pr evention 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 Coordi nator (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	recordk eeping	burden	for	this	collecti on	of	information	is	estimated	t o	range	from	6	to	120	hours	per response.		Send comments	on	the	Agency's	need	for	this	information,	the	accurac y	of	the	provided	burden	estimat es,	and	any	suggested	methods	f or	minimizing respondent	burden,	including	through	the	use	of	automated	colle ction	techniques	to	the	Director,	Collection	Strategies	Divisio n,	U.S. Environmental	Protection	Agenc y	(2822T),	1200	Pennsylvania	Ave. ,	NW,	Washington,	D. C.	20460.		Include	the	OMB	control	number	i n	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 LocationPhysical Hazard Fire

Sudden Release of Pressure

ReactiveHealth 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