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:_PFOA and salts__ 

 

 CAS number:________________________ 

II. COMPANY IDENTIFICATION

Identify the company and location of the facility submitting information: 

 

 Company name:_AGC SEIMI CHEMICAL CO.,LTD

 

 Site location:3-2-10,Chigasaki,Chigasaki City,Kanagawa,253-8585 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 Japan
III. 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 above for the reporting year at specific site: 

 

 Imported (virgin) ___0_______kgs/yr 

 Imported (externally recycled) ___0_______kgs/yr 

 

 Manufactured __CBI ____kgs/yr 

 (as impurities) 

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 additional 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 process. 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 individual 

process. 
Narrative Description and Process Flow Schematic: 

 CBI

 

 

 

 

 
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 per 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 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 (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 storage 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 system. 

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 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 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 

chemical 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 

accumulation 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 land 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) (Optional) 

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 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 wastewater containing the chemical. Enter the POTW’s NPDES permit 

number, if known. 

Annual Transfer (kgs): _____ 

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 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 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 responses. Attach additional pages if desired.)