  Check if information below is identical to the information submitted last year.	
                                                        Tier Two
                                 Emergency and Hazardous Chemical Inventory
                                         Specific Information by Chemical
 For Official Use Only
 State ID#:
 Date Received
 Facility Identification
 Name	Maximum No. of Occupants:	 Manned	Unmanned
                                                     N/A
 Street	County	City	State	Zip
 Latitude	Longitude	NAICS Code	Phone Number (optional)
                                                                            (	)
 Dun & Bradstreet Number	TRI Facility ID:	RMP Facility ID:
                                   N/A	 N/A
 Subject to Emergency Planning under Section 302 of EPCRA (40 CFR part 355)?  	 Yes  	 No  
 Subject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68, Risk Management Program)?  	 Yes  	 No  
 Owner or Operator Information
 Parent Company Information (optional)
 Name
 Name	Dun & Bradstreet Number:
 Address
 Address
 Phone Number	Email
 (	)
 Phone Number	Email
 (	)
 Facility Emergency Coordinator (if applicable)	Tier II Information Contact
 Name	Title
 Name	Title
 Email Address
 Email Address
 Phone Number	24-hour Phone
 (	)	(	)
 Phone Number
 (	)
                                                  Emergency Contacts
 Name
 Name
 Title
 Title
 Phone Number	24-hour Phone
 (	)	(	)
 Phone Number	24-hour Phone
 (	)	(	)
 Email Address
 Email Address
   Certification (Read and sign after completing all sections)
                                        Reporting Ranges
                                    Weight Range in pounds


    I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through
   , and that based on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is
                                true, accurate and complete.

     Name and official title of owner/operator OR owner/operator's authorized representative

      ____________________         _____________ 
   Signature	Date Signed
   Range Code	From	To

      01	0	99
      02	100	499
      03	500	999
      04	1,000	4,999
      05	5,000	9,999
      06	10,000	24,999
      07	25,000	49,999
      08	50,000	74,999
      09	75,000	99,999
      10	100,000	499,999
      11	500,000	999,999
      12	1,000,000	9,999,999
      13	10,000,000	Greater than 10 million
 This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050-0072). Responses to this collection of information are mandatory (40 CFR 370). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to range from 6 to 120 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.



                             Chemical Description
                               Physical Hazards
                                Health Hazards
                                   Inventory
                                Type of Storage
                  Storage Conditions (Pressure, Temperature) 
                              Storage 
Locations
                  Additional Reporting Information (Optional)

  Check if information below is identical to the information submitted last year.


 Chemical Name:
 
 CAS No.
 
 EHS:   Yes  	No  
 
 
  Solid    Liquid   Gas        
 
  Trade Secret

    Explosive
       Flammable (gases, aerosols, liquids, or solids)
       Oxidizer (liquid, solid or gas)
    Self-reactive
       Pyrophoric (liquid or solid)
       Pyrophoric Gas
    Self-heating
    Organic peroxide
    Corrosive to metal
       Gas under pressure (compressed gas)
       In contact with water emits flammable gas
    Combustible Dust
       Hazard Not Otherwise 
Classified
 
 
       Acute toxicity (any route of exposure)
    Skin corrosion or irritation 
       Serious eye damage or eye irritation 
       Respiratory or skin 
sensitization
    Germ cell mutagenicity
       Carcinogenicity
    Reproductive toxicity
       Specific target organ toxicity (single or repeated exposure) 
    Aspiration hazard
    Simple Asphyxiant 
       Hazard Not Otherwise 
Classified


 Maximum Amount
 Range Code:



 Confidential:
  Yes     No

  Below Reporting 
Thresholds (optional)
 
 
  State 
or Local
 Requirements




 Average Daily
 Amount
 Range Code:








 No. of days on site:






  Check if information below is identical to the information submitted last year.
 
 Mixture or Product Name:
 
 CAS No.	
 Not Available
 
  Solid    Liquid   Gas	 Trade Secret

 EHS:   Yes  	No  

    Explosive
       Flammable (gases, aerosols, liquids, or solids)
       Oxidizer (liquid, solid or gas)
    Self-reactive
       Pyrophoric (liquid or solid)
       Pyrophoric Gas
    Self-heating
    Organic peroxide
    Corrosive to metal
       Gas under pressure (compressed gas)
       In contact with water emits flammable gas
    Combustible Dust
       Hazard Not Otherwise 
Classified
 

       Acute toxicity (any route of    exposure)  
    Skin corrosion or irritation 
       Serious eye damage or eye irritation 
       Respiratory or skin 
sensitization
    Germ cell mutagenicity
       Carcinogenicity
    Reproductive toxicity
       Specific target organ toxicity (single or repeated exposure) 
    Aspiration hazard
    Simple Asphyxiant 
    Hazard Not Otherwise 
        Classified


 Maximum Amount (Total Mixture) Range Code:



 Confidential:
  Yes     No

  Below Reporting Thresholds (optional)


  State 
or Local
 Requirements




 Average Daily Amount (Total Mixture) Range Code:





 EHS(s) Name (if applicable):



 CAS No.



 No. of days on site:








 Maximum Amount of each EHS in the Mixture
 Range Code:





 Non-EHS(s) Name (optional):








     Optional Attachments:	 I have attached a site plan	 I have attached a list of site coordinate abbreviations 	 I have attached a description of dikes and other safeguard measures
                                                   
