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# FORM R

Section 313 of the Emergency Planning and Community

Right

- to

- Know Act of 1986, also Known as Title III of the

Superfund Amendments and Reauthorization Act TRI Facility ID Number

Toxic Chemical, Category , or G eneric Name

This section only applies if you are

revising or withdrawing a

p reviously submitted form,

otherwise leave blank. 

### Revision (E nter up to two code(s)) Withdrawal (E nter up to two code(s))

IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.



## PART I . FACILITY IDENTIFICATI ON INFORMATION

SECTION 1. REPORTING YEAR ________

SECTION 2. TRADE SECRET INFORMATION

2.1 Are you claiming the toxic chemical identified on page 2 as a trade secret?

2.2 Is this copy Sanitized Unsanitized

(Answer only if “Y es ” in 2.1) Yes (Answer question 2.2;

a ttach substantiation forms) No (Do not answer 2.2;

g o to Section 3)



## SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)

I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the submitted information is true and complete and

that the amounts and values in this repor t are accurate based on reasonable estimates using data available to the preparers of this report.

Name and official title of owner/operator or senior management official: Signature: Date signed :



## SECTION 4. FACILITY IDENTIFICATION

4.1 Facility or E stablishment Name TRI Facility ID Number

Physical Street Address Mailing Address (if different from physical street address)

City/County/ Tribe/ State/ZIP Code City/State/ZIP Code Country (Non

- US)

4.2 This report contains info rmation for:

(Important: Check a or b; check c or d if applicable) a. An entire

facility b. Part of a

facility c. A federal

facility d. GOC O

4.3 Technical Contact Name Telephone Number (include area code and ext. )

Email Address

4.4 Public Contact Name Telephone Number (include area code and ext. )

Email Address

4.5 NAICS Code(s)

(6 digits) Primary

a. b. c. d. e. f

.

4.6 Dun & Bradstreet

Number (s) (9 digits) a.

b.



## SECTION 5. Parent Company Information

5.1 Name of U.S. Parent Company

(for TRI Reporting p urpose s ) No U

. S . P arent Company

(for TRI Reporting p urpose s )

5.2 Parent Comp any’s Dun & Bradstreet

Number NA

EPA form 9350

- 1 (Rev 10 /20 1 2 )

– Previous editions are obsolete.

# DRAFT

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# FORM R

Part II. CHEMICAL

- SPECIFIC INFORMATION TRI Facility ID Number

Toxic Chemical, Category, or Generic Name



### SECTION 1. TOXIC CHEMICAL IDENTITY

(Important: DO NOT complete this section if you are reporting a mixture component in Section 2 below.)

1.1 CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter categ ory code if reporting a chemical category.)

1.2 Toxic Chemical or Chem ical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.3 Generic Chemical Name (Important: Complete only if P art I , Section 2.1 is c hecked “Y es”. Generic Name must be structurally descriptive.)



### SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you comple ted Section 1.)

2.1 Generic Chemical Name Provided by Supplier (Important: Maximum of 70 cha racters, including numbers, letters, spaces

, and punctuation.)



### SECTION 3. ACTIVITIES AND USES OF THE TOXIC CHEMICAL AT THE FACILITY

(Important: Check all that apply.)

3.1 

### Manufacture the toxic chemical: 3.2 

### Process the toxic chemical: 3.3 

### Otherwi se use the toxic chemical:

a.  Produce b.  Import

a.  As a reactant

b.  As a formulation component

c.  As an article component

d.  Repackaging

e

.  As an impurity a.  As a chemical processing aid

b.  As a manufacturing aid

c.  Ancillary or oth er use If P roduce or I

mport

c.  For on

- site use/processing

d.  For sale/distribution

e.  As a byproduct

f.  As an impurity



### SECTION 4. MAXIMUM AMOUNT OF THE TOXIC CHEMICAL ON

- SITE AT ANY TIME DURING THE

CALENDAR YEAR

4.1 (Enter two digit code from instruction package.)



### SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON

- SITE

A. Total Release (pounds/year*)

( Enter a range code** or estimate) B. Basis of Estimate

( E nter c ode) C. Percent f rom

Stormwater

5.1 Fugitive or non

- point

air emissions NA 

# 

5.2 Stack or point air

emissions NA 

# 

5.3 Discharges to receiving streams or water

bodies ( E nter one name per box) NA 

# 

Stream or Water Body Name Reach Code (optional)

5.3.1

5.3.2

5.3.3

If additional pages of Part II, Section 5.3 are attached, indicate the total number of pages in this box

and indicate the Part II, Section 5.3 page number in this box. (E xam ple: 1, 2, 3, etc.)

EPA form 9350

- 1 (Rev. 10 /201 2 )

– Previous editions are obsolete. *For Dioxin or Dioxin

- like compounds, report in grams/year.

**Range Codes: A= 1

- 10 pounds; B= 11

- 499 pounds; C= 500

- 999 pounds.

# DRAFT

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# FORM R

Part II. CHEMICAL

- SPECIFIC INFO RMATION (CONTINUED) TRI Facility ID Number

Toxic Chemical, Category, or Generic Name



### SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON

- SITE

(continued)

NA A. Total Release (pounds/year*) (Enter a range

code** or estimate) B. Basis of Estimate

(Enter code)

5.4

- 5.5 Disposal to land on

- site

5.4.1 Class I Underground

Injection Wells 

# 

5.4.2 Class II

- V Underground

Injection Wells 

# 

5.5.1A RCRA Subtitle C landfills 

# 

5.5.1B Other landfills 

# 

5.5.2 Land treatment/application

farming 

# 

5.5.3A RCRA Subtitle C surface

impoundments 

# 

5.5.3B Other surface impoundments 

# 

5.5.4 Other disposal 

# 

SECTION 6. TRANSFER(S) OF THE TOXIC CHEMICAL IN WASTES TO OFF

- SITE LOCATIONS

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs) NA 

## 

6.1

.___ POTW Name

POTW Address

City County State ZIP

A. Quantity Transferre d to this POTW

(pounds/year*) (Enter range code**or estimate) B. Basis of Estimate

(Enter code)

If additional pages of Part II, Section 6.1 are attached, indicate the total number of pages in this box

and in dicate the Part II, Section 6.1 page number in this box. (Example: 1, 2, 3, etc.)

SECTION 6.2 TRANSFERS TO OTHER OFF

- SITE LOCATIONS NA 

## 

6.2.___ Off

- Site EPA Identification Number (RCRA ID No.)

Off

- Site Location Name:

Off

- Site Address:

City County State ZIP Country (non

- US)

Is this location under control of reporting facility or parent company? 

# 

Yes 

# 

No

EPA form 9350

- 1 (Rev. 10 /201 2 )

– Previous editions are obsolete. *For Dioxin or Dioxin

- like compoun ds, report in grams/year.

**Range Codes: A= 1

- 10 pounds; B= 11

- 499 pounds; C= 500

- 999 pounds.

# DRAFT

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# FORM R

Part II. CHEMICAL

- SPECIFIC INFORMATION (CONTINUED) TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 6.2. TRANSFERS TO OTHER OFF

- SITE LOCATION (CONTINUED)

A. Total Transfer (pounds/year*)

(E nter a range code** or estimate) B. Basis of Estimate

(E nter code) C. Type of Waste Treatment/Disposal/

Recycling/Energy Recovery (E nter code)

1. 1. 1. M

2

. 2. 2. M

3. 3. 3. M

4. 4. 4. M

6.2____ Off

- Site EPA Identification Number (RCRA ID No.)

Off

- Site Location Name:

Off

- Site Address:

City County State Z IP Country (non

- US)

Is this location under control of reporting facility or parent company ? 

###  Yes 

###  No

A. Total Transfer (pounds/year*)

( E nter a range code** or estimate) B. Basis of Estimate

(E nter code) C. Type of Waste Treatment/Disposal/

Recycling/Energy Recovery (E nter code)

1. 1. 1. M

2. 2. 2. M

3. 3. 3. M

4. 4. 4. M



### SECTION 7A. ON

- SITE WASTE TREATMENT METHODS AND EFFICIENCY

 Not Applicable (NA)

- Check here if no on

- site waste treatment method is applied to any waste stream containing the toxic chemical or chemical category.

a. General Waste Stream

( E nter code ) b. Was te Treatment Method(s) Sequence

( E nter 3

- or 4

- character code(s) ) c . Wa ste Treatment Efficiency

( E nter 2 character code )

7A.1a 7A.1b 1 2

5

8 7A.1 c

3 4

7 6

7 A.2a 7A.2b 1

4 2 7A.2 c

3 5

8 6 7

7A.3a 7A.3 b 1

4

7 2 7A.3 c

3

6 5

8

7A.4a 7A.4b 1

4

7 2

5

8 7A.4 c

3

6

7A.5a 7A.5b 1

4

7 2

5

8 7A.5 c

3

6

If addition al pages of Part II, Section 6 .2/7.A are attached, indicate the total number of pages in this box

and indicate the Part II, Section 6. 2/7.A page number in this box. (Example: 1, 2, 3, etc.)

EPA form 9350

- 1 (Rev. 10 /201 2 )

– Previous editions are obsolete. *For Dioxin or Dioxin

- like compounds, report in grams/year.

**Range Codes: A= 1

- 10 pounds; B= 11

- 499 pounds; C= 500

- 999 pounds.

# DRAFT

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- 0009

Approval Expires : 10 /31/ Page 5 of 6



# FORM R TRI Facility ID Number



## Part II. CHEMICAL

- SPECIFIC INFORMATION (CONTINUED) Toxic Chemical, Category

, o r Generic Nam e



### SECTION 7B. ON

- SITE ENERGY RECOVERY PROCESSES

 NA Check here if no on

- site energy recovery is applied to any waste stream containing the toxic chemical or chemical category.

Energy Recovery Methods ( Enter 3

- character code(s) )

1 2 3



### SECTION 7C. ON

- SITE RECYLING PROCESSES

 NA Check here if no on

- site rec ycling is applied to any waste stream containing the toxic chemical or chemical category.

Recycling Methods (E nter 3

- character code(s) )

1

. 2

. 3

.



### SECTION 8. SOURCE REDUCTION AND WASTE MANAGEMENT

Column A

Prior Year

(pounds/year*) Column B

Current Reporting

Year (pounds/year*) Column C

Following Year

(pounds/year*) Column D

Second Following Year

(pounds/year*)

8. 1

– 8.7 Production

- Related Was te Managed

8.1a Total on

- site disposal to Class I Underground Injection Wells,

RCRA Subtitle C landfills, and other landfills

8.1b Total other on

- site disposal or other releases

8.1c Total off

- site disposal to Class I Underground Injection Well s,

RCRA Subtitle C landfills, and other landfills

8.1d Total other off

- site disposal or other releases

8.2 Quantity used for energy recovery on

- site

8.3 Quantity used for energy recovery off

- site

8.4 Quantity recycled on

- site

8.5 Q uantity recycled off

- site

8.6 Quantity treated on

- site

8.7 Quantity treated off

- site

8.8 Non

- production

- related waste managed**

8.9 

##  Production ratio or 

##  A ctivity ratio (select one and enter value to right)

8.10 Did your facility engage in any newly implemented source reduction activities for this chemical during the reporting year?

If so, complete the following section; if not, check NA. NA 

## 

Source Reduction Activities

(Enter code(s)) Methods to Identify Activity (Enter c ode ( s ) ) Estimated annual reduction

(E nter code (s)) (optional)

8.10.1 a. b

. c. d.

8.10.2 a. b

. c. d.

8.10.3 a. b

. c. d.

8.10.4 a. b

. c. d.

EPA form 9350

- 1 (Rev. 10 /201 2 )

– Previous editions are obsolete. *For Dioxin or Dioxin

- like compounds, repo rt in grams/year.

** Includes quantities released to the environment or transferred off

- site as a result of

remedial actions, catastrophic events, or other one

- ti me events no t associated with pro duction processes

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# FORM R TRI Facility ID Number



## Part II. CHEMICAL

- SPECIFIC INFORMATION (CONTINUED) Toxic Chemical, Category , or Generic Name



### SECTION 8.11. DISPOSAL O R OTHER RELEASES, SOURCE REDUCTION

, AND RECYCLING ACTIVITIES

8.11 If you wish to submit additional optional information on source reduction, recycling, or pollution control activities, provid e it here.



### SECTION 9. MISCELLANEOUS INFORMATION

9.1 If you wish to submit any miscellaneous, additional, or optional information regarding your Form R submission, provide it here.

EPA form 9350

- 1 (Rev. 10 /201 2 )

– Previous editions are obsolete.