 Check if information below is identical to the information submitted last year. 		 Reporting Period: January 1 to December 31, 20____  
                                Confidential Location Information Sheet
                                               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
                                       
                                       
                                       
                                  Range Code
                                                 From
                                                          To
                                       
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.
                                       
                                      01
                                      02
                                      03
                                      04
                                      05
                                      06
                                      07
                                      08
                                      09
                                      10
                                      11
                                      12
                                      13
                                                                              0
                                                                            100
                                                                            500
                                                                          1,000
                                                                          5,000
                                                                         10,000
                                                                         25,000
                                                                         50,000
                                                                         75,000
                                                                        100,000
                                                                        500,000
                                                                      1,000,000
                                                                     10,000,000
                                                                             99
                                                                            499
                                                                            999
                                                                          4,999
                                                                          9,999
                                                                         24,999
                                                                         49,999
                                                                         74,999
                                                                         99,999
                                                                        499,999
                                                                        999,999
                                                                      9,999,999
                                                        Greater than 10 million

                                       





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.  8700-30
OMB Control No. 2050-0072
                                                                               
                                                                 Page  1 of ___
                                       
                                       

EPA Form No.  8700-30
OMB Control No. 2050-0072
                                                                               
                                                                Page  __ of ___
                                       
                             Chemical Description
                          Physical and 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
  
  
  
 Fire
   
 Sudden Release of Pressure
   
 Reactive
   
 Immediate 
   (Acute)
   
 Delayed (Chronic)

Maximum Amount Code:



Confidential:  
 Yes       No

 Below Reporting Thresholds (optional)


 State or Local Requirements

 
           








 
Average Daily Amount 
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   
  

    Fire
   
    Sudden Release of Pressure

    Reactive

   
    Immediate (Acute)
   
    Delayed (Chronic)

Maximum Amount (Total Mixture) 
Code:



Confidential:  
 Yes       No
 Below Reporting Thresholds (optional)


 State or Local Requirements

  

Average Daily Amount (Total Mixture) 
Code:




  EHS(s) Name (if applicable): 
  
  
  
  

No. of days on site:






  CAS No. 

Maximum Amount of EHS in the Mixture
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
