   Check if information below is identical to the information submitted last year.	
                                                Tier One
                               Emergency and Hazardous Chemical Inventory
                                  Aggregate Information by Hazard Type
 For Official Use Only State ID #:
 Date Received:
 Facility Identification
 Name	Maximum No. of Occupants:	  Manned
 	  N/A	  Unmanned
 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?	  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 I 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)
 I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages 1 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/	Signature	Date signed operator OR owner/operator's
    authorized representative
 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 10 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.
                                       
   Check if information below is identical to the information submitted last year.

                                 Hazard 
Types
                            Max Amount (Range Code)
                      Average Daily Amount 
(Range Code)
                            Number of Days On-Site
                               General Location
                                Physical Hazard
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




                                 Health Hazard
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




                                                  REPORTING RANGES

                            WEIGHT RANGE IN POUNDS
                                  Range Codes
                                                                           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
  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
