#  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 Se ction 302 of EPCRA (40 CFR part 355)? 

#  Yes 

#  No

Subject to Chemical Accident Prev ention 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

Range Code From To

I certify under penalty of law that I have personally examined and

am familiar with the information subm itted 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. 01

02

03

04

05

06

07

08

09

10

11

12

13 0

100

500

1,000

5,000

10,000

25,000

50,000

75,000

100,000

500,000

1,000,000

10,000,000 99

499

999

4,999

9,999

24,999

49,999

74,999

99,999

499,999

999,999

9,999,999

Greater than 10 million 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	infor mation,	the	accu racy	of	the	pro vided	burden	estimates,	and	any suggested	methods	for	minimizin g	respondent	burden,

including	through	the	use	of	aut omated	collection	techniques	to the	Director,	Collection	Strate gies	Division,	U.S.	Environment al	Protection	Agency	(2822T),

1200	Pennsylvania	Ave.,	NW,	Wash ington,	D.C.	20460.		Include	th e	OMB	control	number	in	any	corre spondence.		Do	not	send	the	co mpleted	form	to	this

address.



# EPA Form No. 8700-30 OMB Control No. 2050-0072 Page 1 of ___EPA Form No. 8700-30OMB Control No. 2050-0072Page __ of ___Chemical DescriptionPhysical andHealthHazardsInventoryType ofStorageStorageConditions(Pressure,Temperature)StorageLocationsAdditionalReportingInformation(Optional)Check if information below is identical to the information submittedlast year.Chemical Name:CAS No.EHS: YesNoSolidLiquidGasTrade SecretFireSuddenRelease ofPressureReactiveImmediate(Acute)Delayed(Chronic)Maximum AmountRange Code:Confidential:YesNoBelowReportingThresholds(optional)State or LocalRequirementsAverage DailyAmountRange Code:No. of days on site:Check if information below is identical to the information submittedlast year.Mixture or Product Name:CAS No.Not AvailableSolidLiquidGasTrade SecretEHS: YesNoFireSuddenRelease ofPressureReactiveImmediate(Acute)Delayed(Chronic)Maximum Amount(Total Mixture)Range Code:Confidential:YesNoBelowReportingThresholds(optional)State or LocalRequirementsAverage DailyAmount (TotalMixture)Range Code:EHS(s) Name (if applicable):No. of days on site:CAS No.Maximum Amount ofeach EHS in theMixtureRange Code:Non-EHS(s) Name (optional):Optional Attachments:I have attached a site planI have attached a list ofsite coordinate abbreviationsI have attached a description ofdikes and other safeguard measures