# 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,Kashima 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,Chigasaki City,Kanagawa,253

- 8585 JapanIII. ON

- SITE ACTIVITIES

Calendar year for which you are reporting: Jan 1, 20 11 to Dec 31, 20 11

( Normalized data based on year end run rate.)

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

Imported (virgin)

___ 0

_______ kgs/yr

Imported (externally recycled)

___ 0

_______ kgs/yr

Manufactured

___ CBI

___ kgs/yr

Estimate the amount of subject chemical distributed off

- site:

___ 100

____ % 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 chemical being reported, showing releases and

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

schematic of on

- site activities, and include information that gives an understanding of the

nature and extent of potential exposures to the subject chemical. Attach addition al pages if

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

chemical conversions for manufacturing and on

- site uses, if applicable. The narrative should

provide insight into why and how releases are caused by the pr ocess. The schematic should

show the points of release of the subject chemical in the workplace 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 individ ual process.Narrative Description and Process Flow Schematic :IV. SITE RELEASE AND TRANSFER 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 releases 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 numbers to no more than two significant figures.

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

should be reported.

Estimate the number of days pe r year the release 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 b asis 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 (including 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 assumptions 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 calculations are used,

give a general description and state 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 equipment leaks from valves, pump seals, flanges,

compressors, sampling connections, and open

- ended lines; evaporative losses from surface

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

non

- point air emission.

In addition, estimate the total releases that occur through stacks, vents, pipes, or other

confined air streams as stack or point source releases. Include stora ge tank emissions and

releases from pollution control equipment.

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

Estimated Total Estimated % # Days/year

Annual Releases Accuracy 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 syst em

Comments:

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

B. WATER RELEASES FROM SITE

Estimate the total releases of the chemical leaving the fence line of your facility from

all discharge points to all streams or water bodies. Include all discharges from process outfalls

such as pipes, open trenches, releases from on

- site wastewater treatment, and contribution from

storm water runoff, if applicable. Do not include 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 release s:

__ 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.)

Practically, no w aste water (effluent) is generated.

Comments:

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

C. ON

- SITE LAND RELEASES

Estimate the total releases of the chemical 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 c hemical

that is applied or incorporated into soil on

- site. Do not include waste that is landfilled.

Surface impoundments are natural topographic depressions, man

- made excavations, or

diked areas formed primarily of earthen materials designed to hold an ac cumulation of the

chemical.

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

of rocks, through wells or other similar conveyance systems.

Other releases include any amount of the chemical that is released to la nd other than

those listed. An example is the accidental release 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 sect ion is available to clarify your responses. Attach additional pages if desired.)Part IV (cont.)

D. OFF

- SITE TRANSFERS

Estimates of off

- site transfers should be similar in accuracy and precision to previous

release estimates.

Dl. Transfer to Publicly Owned 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

wastewa ter containing the chemical. 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 Sect ion IV.)

Not applicable

Comments:

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

D2. Transfers to other off

- site locations

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

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

subject chemical in waste to an off

- site location where some of the chem ical 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 incl ude 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 responses. Attach additional pages if desired.)