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

(Enter data for one stream or water body per box)

 NA 

Fugitive or nonpoint air emissionsStack or point

air emissions

5.3.1 5.3.2 5.3.3

D. 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

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 (Example: 1, 2, 3, etc.)
EPA Form 9350-3

DRAFT Form Approved OMB Number: 2025-0009

Approval Expires: 10/31/ 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

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 the category (1-17)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17
EPA Form 9350-3

DRAFT Form Approved OMB Number: 2025-0009

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 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 box 

and indicate the Section 6.1 or 6.2 page number in this box (Example: 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 not associated with production processes

EPA Form 9350-3

DRAFT Form Approved OMB Number: 2025-0009 

Approval Expires: 10/31/ Page 4 of 4

FORM R Schedule 1

PART II. CHEMICAL-SPECIFIC INFORMATION (continued)

TRI Facility ID Number

SECTIONS 8.1-8.8. WASTE MANAGEMENT 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

other 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 (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