# Company sanitized

Does not contain Confidential Business

Information (CBI)

Appendix C



# Draft Facility Report on Emissions

## 2010/15 PFOA Stewardship Program



# Draft Facility Report on Emissions

I. CHEMICAL IDENTIFICATION

Identify the chemical for which you are submitting information:

Chemical name:_Precuesors

__

CAS number:________________________

II. COMPANY IDENTIFICATION

Identify the company and location of the facility submitting information:

Company name:_AGC SEIMI CHEMICAL CO.,LTD

Site location:_2276-2,Nada,Hirai,Ka shima City,Ibaraki,314-0012 Japan

Identify a company technical contact who can respond to inquiries about the information

submitted:

Technical contact:__Shunji Odaka____

Phone: _+81-467-82-4398

Address:_3-2-10,Chigasaki,Chigasa ki City,Kanagawa,253-8585 JapanIII. ON-SITE ACTIVITIES

Calendar year for which you are reporting: Jan 1, 2012 to Dec 31, 2012

(Normalized data based on year end run rate.)

Provide the amount of chemical identified abov e for the reporting year at specific site:

Imported (virgin) ___0_______ kgs/yr

Imported (externally recycled) ___0_______ kgs/yr

Manufactured ___0___ kgs/yr

Estimate the amount of subject ch emical distributed off-site:

___0 ___ % of manufacture/import

Provide the amount used (including any that was manufactured, imported [virgin or externally

recycled], or internally recycled ) of the subject chemical for the reporting year at specific site:

____0______ kgs/yr

Narrative Description and Process Flow Schematic :

Provide overall material balance of the chem ical being reported, showing releases and

products (kgs/year). Use the following page to pr ovide a narrative description and process flow

schematic of on-site activities, and include in formation that gives an understanding of the

nature and extent of potential exposures to th e subject chemical. Attach additional pages if

desired. The narrative and pro cess flow schematic should cover major unit operations and

chemical conversions for manufacturing and on- site uses, if applicab le. The narrative should

provide insight into why and how releases ar e caused by the process. The schematic should

show the points of release of th e subject chemical in the workpl ace and to the environment. In

the event the subject chemical is used in many different processes, provide information on each

major process instead of each individual process.Narrative Description and Process Flow Schematic :

No manufacturing activity.IV. SITE RELEASE AND TR ANSFER INFORMATION

(For manufacturing and on-site processing/use if applicable)

In this section, estimate the total media-specific releases after on-site treatment of the

chemical from your facility. You may estimate the re leases by using monitoring data or any

other method you believe appropriate. Estimates should be reported in kgs per year for the

reporting period. Enter the values as whole numbe rs to no more than two significant figures.

For example, if your annual re leases are estimated to be 12,360 kgs, an estimate of 12,000 kgs

should be reported.

Estimate the number of days per year the re lease occurs. Enter a whole number with a

maximum of 2 significant figures.

Insert “NA” for release activities not associated with the chemical or “0” for releases of

less than 0.5 kgs per year.

For all releases, the source of data and/or basis for determination should be described in

detail. Suggested information about the possible sources /basis includes:

1. If the source/basis is an analytical measurement, then

 Describe the method (incl uding analytical standards used, sampling, sample

treatment, analysis).

 Describe the uncertainties and assumptions made.

 Give the Level of Detection (LOD) /Level of Quantification (LOQ).

2. If the source/basis is a mass balance, then

 Show the mass balance calculation.

 Show that the mass balance closes.

 If the mass balance does not close, then report the fraction of total feedstock

that is not accounted for and the assumpti ons you made to correct the balance.

Describe the uncertainties.

3. If the source/basis is other than measurement or mass balance, then

 Describe the method used. For example, if engineering cal culations are used,

give a general description and stat e your assumptions. Describe the

uncertainties.Part IV (cont.)

A. ON-SITE AIR RELEASES

Estimate the total fugitive or non-point releases to air and the number of days per year

the releases occur. These releases include equi pment leaks from valves, pump seals, flanges,

compressors, sampling connections, and open-en ded lines; evaporative losses from surface

impoundments and spills; releases from building ventilation system s; and, any other fugitive or

non-point air emission.

In addition, estimate the total re leases that occur through stac ks, vents, pipes, or other

confined air streams as stack or point sour ce releases. Include stor age tank emissions and

releases from polluti on control equipment.

If desired, you can provide estimates of the accuracies of your release estimates.

Estimated Total Estimated % # Days/year

Annual Releases Accur acy Release Occurs

(kgs) (Optional)

Fugitive (non-point) _0____ _____ __0___

Stack (point) _0____ _____ __0___

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Practically,all operations are conducted under closed system

Comments:

(This section is available to clarify your re sponses. Attach additional pages if desired.)Part IV (cont.)

B. WATER RELEASES FROM SITE

Estimate the total releases of the chemical l eaving the fence line of your facility from

all discharge points to all stream s or water bodies. Include all di scharges from process outfalls

such as pipes, open trenches, releases from on-si te wastewater treatment, and contribution from

storm water runoff, if applicable. Do not incl ude discharges to a POTW or other off-site

wastewater treatment facilities. If desired, you can provide an estimate of the accuracy of your

release estimate.

Estimated Total Estimated % # Days/year

Annual Releases Accuracy Release Occurs

(kgs) (Optional)

Water releases: __0 ___ _____ __0

__

Enter the names of the streams or water bodies to which the facility directly discharges

the chemical. Also, enter the NPDES permit number for the facility. If more than one number

is assigned to the facility, list each number for the appropriate discharge quantity and receiving

water identified.

Receiving Water Name(s):____________

NPDES number(s):_______________

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

No waste water release from the manufacturing process.

Comments:

(This section is available to clarify your re sponses. Attach additional pages if desired.)Part IV (cont.)

C. ON-SITE LAND RELEASES

Estimate the total releases of the chemi cal for each category of land disposal, if

applicable. Estimate only on-site releases. Do not estimate leaks from landfills separately. This

should be accounted for in your estimate of total landfill release.

Releases to land treatment/land amendment include all waste containing the chemical

that is applied or incorporated into soil on-si te. Do not include wast e that is landfilled.

Surface impoundments are natural topographic depressions, man-made excavations, or

diked areas formed primarily of earthen mate rials designed to hold an accumulation of the

chemical.

Underground injection is th e technology of placing fluids underground, in porous formations

of rocks, through wells or other similar conveyance systems.

Other releases include any amount of the chemi cal that is released to land other than

those listed. An example is the accidental re lease of the chemical from an underground

pipeline or storage tank.

Estimated Total Estimated %

Annual Releases Accuracy

(kgs) ( Optiona l)

Landfill __0__

_____

Land Treatment/Land Amendment __0__

_____

Surface Impoundments __0__

_____

Underground Injection __0__

_____

Other (specify): __0__

_____

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Comments:

(This section is available to clarify your re sponses. Attach additional pages if desired.)Part IV (cont.)

D. OFF-SITE TRANSFERS

Estimates of off-site transfers should be si milar in accuracy and precision to previous

release estimates.

Dl. Transfer to Publicly Own ed Treatment Works (POTW)

Number of days/year the release occurs: __0

__

Estimate the total quantity of the subject chemical , not the waste stream, transferred to

the POTW. Complete section below for each POTW to which your facility discharges

wastewater containing the ch emical. Enter the POTW’s NPDES permit number, if known.

Annual Transfer (kgs): __0___

Estimated % Accuracy of Transfer Estimate (optional) _____

POTW Name:____________________________

Street Address: ___________________________________________

City: ________________ County: ______________

State: _____ Zip Code: _____

NPDES number: _______________________

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Not applicable

Comments:

(This section is available to clarify your re sponses. Attach additional pages if desired.)Part IV (cont.)

D2. Transfers to othe r off-site locations

In this section, estimate the qua ntity of the subject chemical , not the waste stream,

transferred and the accuracy of the estimate for each category liste d. If your facility sends the

subject chemical in waste to an off-site locati on where some of the chemical will be recycled

and the remainder will be treated, estimate each amount separately (i.e., waste treatment and

recycling activities).

Estimated Annual Estimated %

Transfers (kgs) accuracy

(Optional)

Incineration _ 0_

_____

Wastewater Treatment

(Excluding POTW) __0__

_____

Underground Injection __0__

_____

Hazardous Waste (RCRA

Subtitle C) Landfill __0__

_____

Other Landfill __0__

_____

Recycle or Recovery __0__

_____ (Does not include internally recycled)

Internally Recycled __0__

_____

Unknown or Other __0__

_____

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

Comments:

(This section is available to clarify your re sponses. Attach additional pages if desired.)