 Check if information below is identical to the information submitted last year. 		Reporting Period: January 1 to December 31, 20____
                                            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/ operator OR owner/operator's authorized representative
                                       
                                   Signature
                                       
                                  Date signed
                                       
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, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 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.
EPA Form No. 8700-29
                           OMB Control No. 2050-0072
                                Page  1 of ----


EPA Form No. 8700-29  				OMB Control No. 2050-0072		  Page   -  - ---- of ----

 Check if information below is identical to the information submitted last year.
                                       
                                  Hazard Type
                                  Max Amount
                             Average Daily Amount
                            Number of Days On-Site
                               General Location
                                Physical Hazard
Fire




                                        
Sudden Release of Pressure




                                        
Reactive




                                 Health Hazard
Immediate (acute)





Delayed (acute)




                                       
                                       
                                       
                                       
                               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

