 Check if information below is identical to the information submitted last year. Reporting Period: January 1 to December 31, 20____ 

Confidential Location Information Sheet

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 Section 302 of EPCRA (40 CFR part 355)?  Yes  No 

Subject to Chemical Accident Prevention 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 submitted 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	recordkeeping	burden	for	this	collection	of	information	is	estimated	to	range	from	6	to	120	hours	per	response.		Send	comments	on	

the	Agency's	need	for	this	information,	the	accuracy	of	the	provided	burden	estimates,	and	any	suggested	methods	for	minimizing	respondent	burden,	

including	through	the	use	of	automated	collection	techniques	to	the	Director,	Collection	Strategies	Division,	U.S.	Environmental	Protection	Agency	(2822T),	

1200	Pennsylvania	Ave.,	NW,	Washington,	D.C.	20460.		Include	the	OMB	control	number	in	any	correspondence.		Do	not	send	the	completed	form	to	this	

address.

EPA Form No. 8700-30 OMB Control No. 2050-0072 Page 1 of ___
EPA Form No. 8700-30 OMB Control No. 2050-0072 Page __ of ___

Chemical Description

Physical and 

Health 

Hazards

Inventory Type of 

Storage

Storage 

Conditions

(Pressure, 

Temperature)

Storage 

Locations

Additional 

Reporting

Information 

(Optional)

 Check if information below is identical to the information submitted 

last year.

Chemical Name:

 CAS No.

EHS: Yes  No 

 Solid  Liquid  Gas  Trade Secret

 Fire

 Sudden 

Release of 

Pressure

 Reactive

 Immediate 

(Acute)

 Delayed 

(Chronic)

Maximum Amount 

Code: Confidential: 

 Yes  No

 Below 

Reporting 

Thresholds 

(optional)

 State or Local 

Requirements

 

Average Daily 

Amount 

Code:

 

No. of days on site:

 Check if information below is identical to the information submitted 

last year.

Mixture or Product Name:

CAS No.  Not Available

 Solid  Liquid  Gas  Trade Secret

EHS: Yes  No 

 Fire

 Sudden 

Release of 

Pressure

 Reactive

 Immediate 

(Acute)

 Delayed 

(Chronic)

Maximum Amount 

(Total Mixture) 

Code:

Confidential: 

 Yes  No

 Below 

Reporting 

Thresholds 

(optional)

 State or Local 

Requirements

Average Daily 

Amount (Total 

Mixture) 

Code:

EHS(s) Name (if applicable): No. of days on site:

CAS No. Maximum Amount of 

EHS in the Mixture

Code: Non-EHS(s) Name (optional): 

Optional Attachments:  I have attached a site plan  I have attached a list of site coordinate abbreviations

  I have attached a description of dikes and other safeguard measures