# DRAFT

Form Approved OMB Number: 2025

- 0009

Approval Expires: 10 /31/ Page 1 of

___ 

# TOXICS RELEASE INVENTORY

FORM A

TRI Facility ID Number

This section only applies if you are revising or withdrawing a

previously submitted form, otherwise leave blank. Revision (Enter up to two code(s)) Withdrawal (Enter up to two code(s))

IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.



### PART I . FACILITY IDENTIFICATION INFORMATION

SECTION 1. REPORTING YEAR

_____________

SECTION 2 . TRADE SECRET INFORMATION

2.1 Are you claiming the toxic chemical identified on page 2 as a trade secret?

2.2 Is this copy Sanitized Unsanitized

(Answer only if “Y es ” in 2.1) Yes (Answer question 2.2;

a ttach substantiation forms) No (Do not answer 2.2;

g o to Section 3)



### SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)

I hereby certify that to the best of my knowledge and belief, for each toxic chemical listed in th is statement, the annual reportable amount as defined in

40 CFR 372.27(a), did not exceed 500 pounds for this reporting year and that the chemical was manufactured, processed, or otherwise used in an amount

not exceeding 1 million pounds during this reporting year.

Name and official title of owner/operator or senior management official: Signature: Date s igned :



### SECTION 4. FACILITY IDENTIFICATION

4.1 Facility or Establishment Name TRI Facility ID Number

Physical Street Address Mailing Address (if different from physical street address)

City/County/ Tribe/ State/ZIP Code City/State/ZIP Code Country (Non

- US)

4.2 This report contains in formation for: ( Important : Check c or d if applicable)

c. A Federal facility d. GOCO

4.3 Technical Contact Name Telephone Number (include area code and ext. )

Email Address

4.4 Pub lic Contact Name Telephone Number (include area code and ext. )

Email Address

4.5 NAICS Code(s) (6 digits) Primary

a. b. c. d. e. f.

4. 6 Dun & Bradstreet

Number(s) (9 digits) a.

b.



### SECTION 5. PARENT COMPANY INFORMATION

5.1 Name of U.S

. Parent Company

(for TRI Reporting p urpose s ) No U.S. Parent Company

(for TRI Reporting purpose s )

5.2 Parent Company’s Dun & Bradstreet Number NA

EPA Form 9350

- 2 (Rev. 10 /2011 )

- Previous editions are obsolet e.

# DRAFT

Form Approved OMB Number: 2025

- 0009

Approval Expires: 10 /31/ Page

__ _ of

___ 

# EPA FORM A

PART II. CHEMICAL IDENTIFICATION

Do not use this form for reporting PBT chemicals, including Dioxin and Dioxin

- like Compounds* TRI Facility ID Number

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

1.1 CAS Number (Important: Ente r only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1 .3 Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 a bove)

2.1 Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and pun ctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

1.1 CAS Number (Important: Enter only one number e xactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.3 Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation .)

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

1.1 CAS Number (Important: Enter only one number exactly as it appear s on the Section 313 list. Enter category code if reporting a chemical category.)

1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.3 Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemical Name Provi ded by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

1.1 CAS Number (Important: Enter only one number exactly as it appears on the Section 31 3 list. Enter category code if reporting a chemical category.)

1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.3 Generic Chemical Name (Important: Complete only if Pa rt 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemical Name Provided by Supplier (Im portant: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

*See the TRI Re porting Forms and Instructions m anual for the list of PBT Chemicals (including Dioxin and Dioxin

- like Compounds)

EPA Form 9350

- 2 (Rev. 10 /2011 )

- Previous editions are obsolete. 

### (Make additional copies of this page, if needed)