Document ID: EPA-HQ-TRI-2017-0057-0007
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2017-05-30T04:00Z

Approval Expires: 10/31/	Page 1 of 4
Approval Expires: 10/31/	Page 1 of 4
DRAFT	Form Approved OMB Number: 2025-0009

                                       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 non- point air emissions
      Stack 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
                                                                              	

 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.)

                                                                               

                                          
DRAFT
Form Approved OMB Number: 2025-0009
Approval Expires: 10/31/							Page 2 of 4
                               FORM R Schedule 1
              PART II. CHEMICAL-SPECIFIC INFORMATION (continued)
                            TRI Facility ID Number

 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
                                       
                                    5.5.3.A
                                      NA
                                       
                                    5.5.3.B
                                      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
 
 
 
 
 
 
 
 

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 ___
            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
                                       
                                       
                                    6.1 ___
            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
                                       
                                       
                                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
                                       
                                       
                                    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
                                       
                                       

                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
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.)
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

 
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 Non-production related 
waste managed*
 
                                     8.1a
                                     8.1b
                                     8.1c
                                     8.1d
                                      8.2
                                      8.3
                                      8.4
                                      8.5
                                      8.6
                                      8.7
                                     8.8a
                                     8.8b
                                     8.8c
 
        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
                               Remedial actions
                                       
                              Catastrophic events
                                       
                                One-time events
         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
 
 
 
 
 
 
 
 
 
 
 
 
 
  *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.