## ICR 1 st 

## FR Notice 2/08/11 47 APPENDIX A

BLANK FORMS

FORM A

FORM R

FORM R S CHEDULE 1Form Approved OMB Number: 2025-0009

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



# TOXICS RELEASE INVENTORY

FORM A

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

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 y ou are revising or withdrawing a

previously submitted form, otherwise leave blank.

IMPORTANT: See instructions to determine when “Not Applicable (NA)” b oxes 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, fo r each toxic chemical listed in this statement, the annual repo rtable amount as defined in 40 CFR372.27

(a), did not exceed 500 pounds for this reporting year and that th e chemical was manufactured, pro cessed, or otherwise used in an amount not exceeding 1 million

pounds during this reporting year.

Name and official title of owner/operator or seni or 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

Public Contact Name Telephone Number (include area code) 4.4

Email Address

P r i m a r y

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; ty pe or use fill-and-print form ) Approval Expires: 07/31/2011 Page ___ of ___

TRI Facility ID Number 

# EPA FORM A

PART II. CHEMICAL IDENTIFICATION

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

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

CAS Number (Important: Enter only one number exactly as it a ppears 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 exac tly as it appears on the Section 313 list.)

1.2

Generic Chemical Name (Important: Complete only if Part 1, Sec tion 2.1 is checked “Yes”. Generic Name must be structurally de scriptive.)

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: Maximu m of 70 characters, including num bers, letters, spaces, and punct uation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

CAS Number (Important: Enter only one number exactly as it a ppears 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 exac tly as it appears on the Section 313 list.)

1.2

Generic Chemical Name (Important: Complete only if Part 1, Sec tion 2.1 is checked “Yes”. Generic Name must be structurally de scriptive.)

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: Maximu m of 70 characters, including num bers, letters, spaces, and punct uation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

CAS Number (Important: Enter only one number exactly as it a ppears 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 exac tly as it appears on the Section 313 list.)

1.2

Generic Chemical Name (Important: Complete only if Part 1, Sec tion 2.1 is checked “Yes”. Generic Name must be structurally de scriptive.)

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: Maximu m of 70 characters, including num bers, letters, spaces, and punct uation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY Report ___ of ___

CAS Number (Important: Enter only one number exactly as it a ppears 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 exac tly as it appears on the Section 313 list.)

1.2

Generic Chemical Name (Important: Complete only if Part 1, Sec tion 2.1 is checked “Yes”. Generic Name must be structurally de scriptive.)

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: Maximu m of 70 characters, including num bers, letters, spaces, and punct uation.)

2.1

*See the TRI Reporting Forms and Instructions manual for the lis t 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; ty pe 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 a nd 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 “N ot Applicable (NA)” boxe s 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 a nd that, to the best of my knowle dge and belief, the submitted in formation is true and complete and

that the amounts and values in this report are accurate based on reasonable estimates us ing 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

F acility or Establishment Name T RI Facility ID Number

P hysical Street Address M ailing Address (if different from physical street address)

C ity/County/State/ZIP Code C ity/County/State/ZIP Code C ountry (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.

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 -1 (Rev. 12/2010) – Pr evious editions are obsolete.Form Approved OMB Number: 2025-0009

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

TRI Fa cility ID Number 

# FORM R

Toxic Chemical, Category, or Generic Name 

### Part II. CHEMICAL-SPECIFIC INFORMATION

SECTION 1. TOXIC CHEMICAL IDENTITY (Important: DO NOT complete this section if you are reporting a mixture in Section 2

below.)

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

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

Generic Chemical Name (Important: Complete only if Part I, Secti on 2.1 is checked “Yes”. Generic Name must be structurally desc riptive.) 1.3



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

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including num bers, letters, spaces, and punctu ation.) 2.1



### 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 att ached, 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 co mpounds, 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; ty pe or use fill-and-print form ) Approval Expires: 07/31/2011 Page 3 of 6

TRI Fa cility 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 CHEM ICAL 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 Transfe rred 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 att ached, 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 re porting facility or parent company? 

# 

Yes 

# 

No

EPA form 9350 -1 (Rev. 12/2010) – Previous editions are obsolete. *For Dioxin or Dioxin-like co mpounds, 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; ty pe or use fill-and-print form ) Approval Expires: 07/31/2011 Page 4 of 6

TRI Facility ID Number 

# FORM R

Toxic Chemical, Category, or Generic Name 

### Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

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 Identifica tion 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 TREATM ENT METHODS AND EFFICIENCY

 Not Applicable (NA) - Check here if no on-s ite waste treatment method is applied to any waste stream containing the toxic chemi cal 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 att ached, 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 co mpounds, 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; ty pe or use fill-and-print form ) Approval Expires: 07/31/2011 Page 5 of 6

TRI Facility ID Number 

# FORM R

Toxic Chemical, Category, or Generic Name 

### Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

SECTION 7B. ON-SITE ENERGY RECOVERY PROCESSES

 NA Check here if no on-site energy recovery is applied to any wast e 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 REDUCTIO N, 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 Cla ss 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 Cl ass 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 r ecovery 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 enviro nment 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 rep orting 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 co mpounds, 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) A pproval Expires: 07/31/2011 Page 6 of 6

TRI Facility ID Number 

# FORM R

Toxic Chemical, Category, or Generic Name 

### Part II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

SECTION 8.11. DISPOSAL OF OTHER RELEASES, SOURCED REDUCTION, AND RECYCLING ACTIVITIES

8.11 If you wish to submit additional optiona l information on source reducti on, recycling, or pollution control activities, provide it here.



### SECTION 9. MISCELLANEOUS INFORMATION

9.1 If you wish to submit any miscellaneous, additional, or optiona l 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 co mpounds, 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

( 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

- 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 N A 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 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

- 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 ( E xample: 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 Exp ires: 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

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 Quan tity

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 ( 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