 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 

Chemical Description 

Physical and 

Health 

Hazards 

Inventory Type of Storage 

Storage 

Conditions 

(Pressure, 

Temperature) 

 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 Range Code:

Average Daily Amount Range 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) Range Code: 

Average Daily Amount (Total Mixture) Range Code: 

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

Maximum Amount of each EHS in the Mixture Range 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