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

## Tier T**wo 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 & Brad

street 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 & Bra dstreet 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 Gr eater 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	minimizi ng	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	c ompleted form to	this address. 

### EPA Form No. **8700 -**  **30 OMB Control No. 2050**  **- 0072**  **Pag e 1 of ___** 

### EPA Form No. **8700 -**  **30 OMB Control No. 2050**  **- 0072**  **Pag e __ of ___** 

**Chemical Description Ph**  **ys ical and**  **Health Hazards**  **Inventory Ty**  **pe 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 

###  Reactiv e 

###  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: CA** **S No.** 

###  **Not Available**  Solid  Liquid  Gas  Trade Secret EHS: Yes  No  

###  Fire 

###  Sudden Release of Pressure 

###  Reactiv e


###  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