Document ID: EPA-HQ-TRI-2017-0057-0020
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2017-09-29T04:00Z

TOXICS RELEASE INVENTORY FORM A

  TRI Facility ID Number
  

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

 2.1
Are you claiming the toxic chemical identified on page 2 as a trade secret?

 2.2
             

 Yes  (Answer question 2.2; attach substantiation forms)

 No  (Do not answer 2.2; go to Section 3)

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 CFR 372.27(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

 4.1
 Facility or Establishment Name

 TRI Facility ID Number
 
 BIA Code

 

 Physical Street Address

 Mailing Address (if different from physical street address)

 City/County/State/ZIP Code

 City/State/ZIP Code

 Country (Non-US)

 4.2
This report contains information for: (Important: Check c or d if applicable)

 
 

                                                                             c.
                                                                               
 
 A Federal Facility
                                                                               
                                                                             d.
                                                                             d.
                                                                               

 GOCO
 

 4.3
Technical Contact Name

Telephone Number (include area code and ext.)

Email Address

 4.4
Public Contact Name

Telephone Number (include area code and ext.)

Email Address

 4.5

NAICS Code(s) (6 digits)
    Primary

b.

c.

d.

e.

f.

a.

 4.6
Dun & Bradstreet Number(s) (9 digits)
a.

b.
SECTION 5. PARENT COMPANY INFORMATION

 5.1
 Name of U.S. Parent Company (for TRI Reporting purposes)

 

No U.S. Parent Company

 

(for TRI Reporting purposes)
 5.2
Parent Company's Dun & Bradstreet Number
 

 

 NA

 

 

 EPA Form 9350 -2 (Rev. 09/2017). Previous editions are obsolete.
 
                                  EPA FORM A
                       PART II. CHEMICAL IDENTIFICATION
Do not use this form for reporting PBT chemicals, including Dioxin and Dioxin-like Compounds*
TRI Facility ID Number

                         

SECTION 1. TOXIC CHEMICAL IDENTITY	Report	of  	
 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 1, 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 above)
   
 2.1
Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

   

SECTION 9.2. OPTIONAL POLLUTION PREVENTION AND ADDITIONAL INFORMATION FOR THIS TOXIC CHEMICAL
 9.2

If you wish to provide optional chemical specific pollution prevention or additional information, provide it here.
 

SECTION 1. TOXIC CHEMICAL IDENTITY	Report	of  	
 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 1, 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 above)
   
 2.1
Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

   

SECTION 9.2. OPTIONAL POLLUTION PREVENTION AND ADDITIONAL INFORMATION FOR THIS TOXIC CHEMICAL
 9.2

If you wish to provide optional chemical specific pollution prevention or additional information, provide it here.
 

 

 *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. 09/2017). Previous editions are obsolete.	(Make additional copies of this page, if needed)