ICR 1st FR Notice 2/08/11 

47

APPENDIX A 

BLANK FORMS 

FORM A 

FORM R 

FORM R SCHEDULE 1 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page ___ of ___ 

TOXICS RELEASE INVENTORY 

FORM A 

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

 P. O. Box 10163 (See instructions in Appendix E) 

 Fairfax, VA 22038 

Revision (Enter up to two code(s)) Withdrawal (Enter up to two code(s)) This section only applies if you are revising or withdrawing a 

previously submitted form, otherwise leave blank. 

 

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 

Are you claiming the toxic chemical identified on page 2 as a trade secret? 

2.1 Yes (Answer question 2.2; 

attach substantiation forms) 

No (Do not answer 2.2; 

 go to Section 3) 

2.2 Is this copy Sanitized Unsanitized 

(Answer only if “Yes” in 2.1) 

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 this statement, the annual reportable amount as defined in 40 CFR372.27 

(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 Signed 

SECTION 4. FACILITY IDENTIFICATION 

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/County/State/ZIP Code Country (Non-US) 

4.1 

4.2 This report contains information for: (Important: Check c or d if applicable) c. A Federal facility d. GOCO 

Technical Contact Name Telephone Number (include area code) 

4.3 

Email Address 

4.4 Public Contact Name Telephone Number (include area code) 

Email Address 

Primary

4.5 NAICS Code(s) (6 digits) 

a. b. c. d. e. f. 

a. 4.6 Dun & Bradstreet 

Number(s) (9 digits) b. 

SECTION 5. PARENT COMPANY INFORMATION 

5.1 Name of Parent Company 

 

5.2 Parent Company’s Dun & Bradstreet Number NA 

EPA Form 9350 -2 (Rev. 12/2010) - Previous editions are obsolete. 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page ___ of ___ 

EPA FORM A TRI Facility ID Number 

PART II. CHEMICAL IDENTIFICATION 

Do not use this form for reporting PBT chemicals, including Dioxin and Dioxin-like Compounds* 

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___ 

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

1.1 

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

1.2 

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

1.3 

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

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

2.1 

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___ 

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

1.1 

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

1.2 

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

1.3 

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

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

2.1 

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___ 

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

1.1 

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

1.2 

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

1.3 

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

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

2.1 

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___ 

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

1.1 

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

1.2 

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

1.3 

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

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

2.1 

*See the TRI Reporting Forms and Instructions manual for the list of PBT Chemicals (including Dioxin and Dioxin-like Compounds)

EPA Form 9350 -2 (Rev. 12/2010xx) - Previous editions are obsolete. (Make additional copies of this page, if needed) 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page 1 of 6 

TRI Facility ID Number 

Toxic Chemical, Category, or Generic Name 

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 

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 (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

Are you claiming the toxic chemical identified on page 2 as a trade secret? 

2.1 Yes (Answer question 2.2; 

attach substantiation forms) 

No (Do not answer 2.2; 

go to Section 3) 

2.2 Is this copy Sanitized Unsanitized

(Answer only if “Yes” in 2.1) 

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: 

SECTION 4. FACILITY IDENTIFICATION

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/County/State/ZIP Code Country (Non-US) 

4.1 

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 

Telephone Number (include area code) Technical Contact Name 

4.3 

Email Address 

Telephone Number (include area code) Public Contact Name 

4.4 

Email Address 

Primary 4.5 NAICS Code(s) 

(6 digits) a. b. c. d. e. f. 

4.6 Dun & Bradstreet a. 

Number(s) (9 digits) b. 

SECTION 5. Parent Company Information

5.1 Name of Parent Company 

5.2 Parent Company’s Dun & Bradstreet 

Number 

NA 

EPA form 9350 -1 (Rev. 12/2010) – Previous editions are obsolete. 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page 2 of 6 

TRI Facility ID Number 

FORM R

Part II. CHEMICAL-SPECIFIC INFORMATION Toxic Chemical, Category, or Generic Name 

SECTION 1. TOXIC CHEMICAL IDENTITY (Important: DO NOT complete this section if you are reporting a mixture 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 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 I, 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.)

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 

 If Produce or Import 

 c.  For on-site use/processing 

 d.  For sale/distribution 

 e.  As a by-product 

 f.  As an impurity 

a.  As a reactant 

b.  As a formulation component 

c.  As an article component 

d.  Repackaging 

d.  As an impurity 

a.  As a chemical processing aid 

b.  As a manufacturing aid 

c.  Ancillary or other use 

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

 (Enter code) 

C. Percent from Stormwater 

5.1 Fugitive or non-point 

air emissions NA 

5.2 Stack or point 

emissions NA 

5.3 Discharges to receiving 

streams or water bodies 

(Enter 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. (Example: 1, 2, 3, etc.) 

EPA form 9350 -1 (Rev. 12/2010) – 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. 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page 3 of 6 

TRI Facility ID Number 

FORM R

 Toxic Chemical, Category, or Generic Name Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

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._ POTW Name

POWT 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.) 

SECTION 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. 12/2010) – 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. 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page 4 of 6 

TRI Facility ID Number 

FORM R

Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED) Toxic Chemical, Category, or Generic Name 

SECTION 6.2. TRANSFERS TO OTHER OFF-SITE LOCATION (CONTINUED) 

A. Total Transfer (pounds/year*) 

 (Enter a range code** or estimate) 

B. Basis of Estimate

 (Enter code) 

C. Type of Waste Treatment/Disposal/ 

 Recycling/Energy Recovery (Enter 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 ZIP Country (non-US)

Is location under control of reporting facility or parent company? Yes  No 

A. Total Transfer (pounds/year*) 

 (Enter a range code** or estimate) 

B. Basis of Estimate

 (Enter code) 

C. Type of Waste Treatment/Disposal/ 

 Recycling/Energy Recovery (Enter 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 

 (Enter code) 

b. Waste Treatment Method(s) Sequence 

 (Enter 3- or 4-character code(s)) 

d. Waste Treatment Efficiency

 (Enter 2 character code) 

7A.1a 7A.1.b 1 2 7A.1c 

3 4 5 

6 7 8 

7A.2a 7A.2.b 1 2 7A.2c 

3 4 5 

6 7 8 

7A.3a 7A.3.b 1 2 7A.3c 

3 4 5 

6 7 8 

7A.4a 7A.4.b 1 2 7A.4c 

3 4 5 

6 7 8 

7A.5a 7A.5.b 1 2 7A.5c 

3 4 5 

6 7 8 

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.) 

EPA form 9350 -1 (Rev. 12/2010) – 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. 
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form) Approval Expires: 07/31/2011 Page 5 of 6 

TRI Facility ID Number 

FORM R

Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED) Toxic Chemical, Category, or 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 recycling is applied to any waste stream containing the toxic chemical or chemical category. 

Recycling Methods (Enter 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 

8.1.a Total on-site disposal to Class I Underground Injection Wells, 

RCRA Subtitle C landfills, and other landfills 

8.1.b Total other on-site disposal or other releases 

8.1.c Total off-site disposal to Class I Underground Injection Wells, 

RCRA Subtitle C landfills, and other landfills 

8.1.d 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 source reduction activities (newly implemented and/or ongoing) for this chemical during the reporting year? 

If so, complete the following section; if not, check NA. NA 

Source Reduction 

Activities (Enter 

code(s)) 

Is Activity New? 

(Yes/No) 

Methods of 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. 12/2010) – 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.
Form Approved OMB Number: 2025-0009 

(IMPORTANT: Type or print; read instructions before completing form) Approval Expires: 07/31/2011 Page 6 of 6 

TRI Facility ID Number 

FORM R

Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED) Toxic Chemical, Category, or Generic Name 

SECTION 8.11. DISPOSAL OF OTHER RELEASES, SOURCED 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. 12/2010) – 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. 
EPA Form 9350-3

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form)

Form Approved OMB Number: 2025-0007 

Approval Expires: 07/31/2011 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

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form)

Form Approved OMB Number: 2025-0007 

Approval Expires: 07/31/2011 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 o-nsite

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

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 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

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form)

Form Approved OMB Number: 2025-0007 

Approval Expires: 07/31/2011 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.A.3 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 6.2 are attached, indicate the total number of pages in this box 

and indicate the Section 6.2 page number in this box (Example: 1, 2, 3, etc.)
EPA Form 9350-3

(IMPORTANT: Read instructions before completing form; type or use fill-and-print form)

Form Approved OMB Number: 2025-0007 

Approval Expires: 07/31/2011 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 DIOXIN 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 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 

Quantity released to

the environment as a

result of remedial 

actions, catastrophic

events, or one-time

events not associated

with production 

processes

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