# 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 f or 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 CHEM ICAL 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:

Phone: __ Shunji Odaka

____

Address: _ +81

- 467

- 82

- 4398

_ 3

- 2

- 10,Chigasaki,Chigasaki City,Kanagawa,253

- 8585 JapanIII. ON

- SITE ACTIVITIES

Calendar year for which you are reporting: Jan 1, 20 10 to Dec 31, 20 10

( Normalized data based on year end run rate )

Provide the amount of chemical i dentified above for the reporting year at specific site:

Imported (virgin)

___ 0

_______ kgs/yr

Imported (externally recycled)

___ 0

_______ kgs/yr

Manufactured

__ CBI

____ (a s impurities ) kgs/yr

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 re ported, 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 exposure s 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 :

CBIIV.

(For manufacturing and on

- site processing/use if applicable) SITE RELEASE AND TRANSFER INFORMATION

In this section, estimate the total media

- specific releases after on

- site treatment of

the che mical 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

signi ficant 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.

Inse rt “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 possi ble 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 D etection (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 no t 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 emissi on.

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 provi de 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 additiona l 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 outfa lls 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

est imate 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 fa cility 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 Nam e(s):____________

NPDES number(s):_______________

Basis for each release estimate:

(See discussion on source/basis in beginning of Section IV.)

CBI

Comments:

(This section is available to clarify your responses. Attach additional pages if de sired.)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, th rough 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.

Estim ated Total Estimated %

Annual Releases Accuracy

(kgs) ( Optiona l)

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

Estimate s 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 chem ical , 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 % Ac curacy 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) accurac y

(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.)