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 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 Se ction 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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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 S ubtitle 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 OMB 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 T RANSFERS 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 ( 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 9350

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# FORM R Schedule 1

PART II. CHEMICAL

- SPECIFIC INFORMATION (continued) TRI Facility ID Number

S ECTION 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 S ubtitle

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

- si te Quantity

treated

off

- site Non

- production

related waste

managed *

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

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17