EPA Form 9350

- 3 

# DRAFT Form Approved OMB Number: 2025

- 0009

Approval Expires : 10 /31/ Page 1 of 4

United States

Environmental Protection

Agency 

# 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

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

( E nter data for one stream 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 Section 5.3 page number in this box (E xample: 1, 2, 3, etc.)EPA Form 9350

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# DRAFT Form Approved OMB Number: 2025

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# F ORM 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

5.4

– 5.5 Disposal to land on

- site

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

Class I

Underground

Injection Wells Class II

- V

Underground

Injection 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

17EPA Form 9350

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# DRAFT Form Approved O MB Number: 2025

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Approval Expires: 10 /31/ 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 (POTWs) NA

6.1.

__ C

. Mass (grams) of Each Compound in the Category (1

- 17)

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

6.2 TRANSFERS TO OTH ER 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 Secti on 6.1 or 6.2 are attached, indicate the total number of pages in this box

and indicate the Section 6.1 or 6.2 page number in this box ( E xample: 1, 2, 3, etc.)*Includes quantities released to the environment or transferred off

- site as a result of remedial actions, catastrophic events, or other one

- time events no t associated with pro duction processes EPA Form 93 50

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# FORM R Schedule 1

PART II. CHEMICAL

- SPECIFIC INFORMATION (continued) TRI Facility ID Number

SECTION S 8 .1

- 8. 8

. WASTE MANAGE MENT QUANTITIES FOR DIOXIN AND DIOXIN

- LIKE COMPOUNDS (current year only)

8.1

- 8.7 Production

- related waste managed

8.8

8.1a 8.1b 8.1c 8.1d 8.2 8.3 8.4 8.5 8.6 8 .7

Total on

- site

disposal to

Class 1

Underground

Injection Wells,

RCRA Subtitle

C landfills, and

other landfills Total other

on

- site disposal

or other

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

- site Quantity

recycled

on

- site Quantity

recycled

off

- site Quantity

treated

on

- site Quantity

treated

off

- site Non

- production

related waste

managed *

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

1 7