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___ 

# TOXICS RELEASE INVENTORY

FORM A

WHERE TO SEND COMPLETED FORMS: 1. TRI Data Processing Center 2. APPROPRIATE STATE OFFICE OR

P. O. Box 10163 (See instruction s in Appendix E)

Fairfax, VA 22038 TRI Facility ID Number

This section only applies if you are revising or withdrawing a

previously submitted form, otherwise leave blank. Revision (Enter up to two code(s)) Withdrawal (Enter up to two code(s))

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



### PART I . FACILITY IDENTIFICATION 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 to the best of my knowledge and belief, for each toxic chemical listed in th is statement, the annual reportable amount as defined in

40 CFR 372.27(a), did not exceed 500 pounds for this reporting year and that the chemical was manufactured, processed, or otherwise used in an amount

not exceeding 1 million pounds during this reporting year.

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



### SECTION 4. FACILITY IDENTIFICATION

4.1 Facility or Establishment Name TRI Facility ID Number

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

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

- US)

4.2 This report contains informat ion for: ( Important : Check c or d if applicable)

c. A Federal facility d. GOCO

4.3 Technical Contact Name Telephone Number (include area code)

Email Address

4.4 Public Contact Nam e Telephone Number (include area code)

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 TR I Reporting p urpose s ) No U

. S . P arent Company

(for TRI Reporting p urpose s )

5.2 Parent Company’s Dun & Bradstreet Number NA

EPA Form 9350

- 2 (Rev. 0 7 /2011 )

- Previous editions are obsolete.DRAFT

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___ 

# EPA FORM A

PART II. CHEMICAL IDENTIFICATION

Do not use this form for reporting PBT chemicals, including Dioxin and Dioxin

- like Compounds* TRI Facility ID Number

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

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

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

1.3 Gene ric Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally desc riptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and pun ctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

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

1.2 Toxic Chemical or Chemical 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 Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemica l Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

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

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

1.3 Generic Chemical Name (Important: Complet e only if Part 1, Section 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

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

1.2 Toxic Chemical or Chemical 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 Part 1, S ection 2.1 is checked “Yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1 above)

2.1 Generic Chemical Name Provided by Supplier (Important : Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

*See the TRI Re porting Forms and Instructions m anual for the list of PBT Chemicals (including Dioxin and Dioxin

- like Compounds)

EPA Form 9350

- 2 (Rev. 0 7 /2011 )

- Previo us editions are obsolete. 

### (Make additional copies of this page, if needed)DRAFT

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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 Generic Name

WHERE TO SEND COMPLETED FORMS: 1. TRI Data Processing Center

P. O. Box 10163

Fairfax, VA 22038 2. APPROPRIATE STATE OFFICE

(See instructions in Appendix E)

This section only applies if you are

revising or withdrawing a

previously 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 IDENTIFICATION 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 report 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 Establishment Name TRI Facility ID Number

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

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

- US)

4.2 This report contains information 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. GOCO

4.3 Technical Contact Name Telephone Number (include area code)

Email Address

4.4 Public Contact Name Telephone Number (include area code)

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 Company’s Dun & Bradstreet

Number NA

EPA form 9350

- 1 (Rev. 0 7 /20 1 1 )

– 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 category 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 checked “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 characters, 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 

### Otherwise 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 other 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 code) 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

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 xample: 1, 2, 3, etc.)

EPA form 9350

- 1 (Rev. 0 7 /2011 )

– 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 INFORMATION (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)

5.4.1 Underground Injection on

- site

to Class I Wells 

# 

5.4.2 Underground Injection on

- site

to Class II

- V Wells 

# 

5.5 Disposal to land on

- site

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. B.

_ POTW Name

POT W Address

City County State ZIP

A. Quantity Transferred 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 indicate the Part II, Section 6.1 page number in this box. (Example: 1, 2, 3, etc.)

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. 0 7 /2011 )

– 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 INFORMATION (CONTINUED) TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

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

7A.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. 0 7 /2011 )

– Previous editions are obsolete. *For Dioxin or Dioxin

- like compounds, report in grams/year.

**Range Codes: A= 1

- 10 pounds; B= 1 1

- 499 pounds; C= 500

- 999 pounds.DRAFT

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# FORM R TRI Facility ID Number



## Part II. CHEMICAL

- SPECIFIC INFORMATION (CONTINUED) Toxic Chemical, Category

, o r Generic Name



### 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. DISPOSAL OR OTHER RELEASES, SOURCE REDUCTION, AND RECYCLING ACTIVITIES

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

8.1a 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 Wells,

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 Quantity recycled off

- site

8.6 Quantity treated on

- site

8.7 Quantity treated off

- site

8.8 Quantity released to the environment as a result of remedial actions, catastrophic events, or one

- time events

not associated with production processes (pounds/year*)

8.9 Production ratio or activity index

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 codes)

8.10.1 a. b. c.

8.10.2 a. b. c.

8.10.3 a. b. c.

8.10.4 a. b. c.

EPA form 9350

- 1 (Rev. 0 7 /2011 )

– Previous editions are obsolete. *For Dioxin or Dioxin

- like compounds, report in grams/year.DRAFT

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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, provide 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. 07 /2011 )

– Previous editions are obsolete.

### EPA Form 9350

- 3

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### Page 1 of 4

United States

Environmental Protection

Agency 

# FORM R Schedule 1 TRI Facility ID Nu mber



# PART II. CHEMICAL

- SPECIFIC INFORMATION (continued)

SECTION 5. QUANTITY OF DIOXIN AND DIOXIN

- LIKE COMPOUNDS ENTERING EACH ENVIRONMENTAL MEDIUM ON

- SITE

5.1 NA 5.2 NA 5.3 Discharges to receiving streams or water bodies

( E nter data for one stre am or water body per box) NA

Fugitive or non

point air emissions Stack or point

air emissions 

### 5.3.1 5.3.2 5.3.3

D. Mass ( g rams) of each compound in the cat egory (1 - 17) 

### 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

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

and indicate the Sec tion 5.3 page number in this box (E xample: 1, 2, 3, etc.)

### EPA Form 9350

- 3

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### Page 2 of 4



# FORM R Schedule 1 TRI Facility ID Number



# PART II. CHEMICAL

- SPECIFIC INFORMATION (continued)

SECTION 5. QUANTITY OF DIOXIN AND DIOXIN

- LIKE COMPOUNDS ENTERING EACH ENVIRONMENTAL MEDIUM ON

- SITE

Underground Injection 5.5 Disposal to land on

- sit e

5.4.1 NA 5.4.2 NA 5.5.1 A NA 5.5.1B NA 5.5.2 NA 5.5.3A NA 5.5.3B NA 5.5.4 NA

Underground

Injection on

- site

to Class I Wells Underground

Injection on

- site

to Class II

- V

Wells RCRA Subtitle C

landfills Other landfills Land treatment/

application farming RCRA Subtitle C

surface

impoundments Other surface

impoundments Other disposal

C. Mass ( grams) of each compound in t he ca tegory (1 - 17) 

### 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

### EPA Form 9350

- 3

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### Page 3 of 4



# FORM R Schedule 1

PART II. CHEMICAL

- SPECIFIC INFORMATION (continued) TRI Facility ID Number

SECTION 6. TRANSFERS OF DIOXIN AND DIOXIN

- LIKE COMPOUNDS IN WASTES TO OFF

- SITE LOCATIONS

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (P OTWs) NA

6.1.A.3 Mass (grams) of e ach c ompound in the c ategory (1

- 17)



### 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

6.2 TRANSFERS TO OTHER OFF

- SITE LOCATIONS NA

6.2.

__ D. Mass (grams) of each compound in the category (1

- 17)



### 1. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 2. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 3. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 4. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 6.2.

__ D. Mass (grams) of each compound in the category (1

- 17)



### 1. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 2. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 3. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### 4. 1 2 3 4 5 6 7 8

9 10 11 12 13 14 15 16 17



### If additional pages of Section 6 .1 or 6.2 are attached, indicate the total number of pages in this bo x

and indicate the Section 6 .1 or 6.2 page number in this box ( E xample: 1, 2, 3, etc.)

### EPA Form 9350

- 3 DRAFT

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### Page 4 of 4



# FORM R Schedule 1

PART II. CHEMICAL

- SPECIFIC INFORMATION (continued) TRI Facility ID Number

SECTION 8. DISPOSAL OR OTHER RELEASES, SOURCE REDUCTION

, AND RECYCLING ACTIVITIES FOR DIOXI N AND DIOXIN

- LIKE COMPOUNDS

(current year only)

8.1a 8.1b 8.1c 8.1d 8.2 8.3 8.4 8.5 8.6 8.7 8.8

Total on

- site

disposal to

Class 1

Underground

Injection Wells,

RCRA Subtitle

C landfills, and

other landfills Total other

on

- site disposal

or ot her

releases Total off

- site

disposal to

Class 1

Underground

Injection Wells,

RCRA Subtitle

C landfills, and

o ther landfills Total other

off

- site disposal

or other

releases Quantity used

for energy

recovery

on

- site Quantity used

for energy

recovery

off

- s ite Quantity

recycled

on

- site Quantity

recycled

off

- site Quantity

treated

on

- site Quantity

treated

off

- site Quantity released to

the environment as a

result of remedial

actions, catastrophic

events, or one

- time

events not associated

with production

p rocesses

Column f. Mass ( g rams) of each compound in the c a tegory (1 - 17) 

### 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17