Kansas Epcra Tier Ii Emergency & Hazardous Chemical Inventory Form - Kansas Department Of Health & Environment

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Kansas EPCRA Tier II Emergency & Hazardous Chemical Inventory

Mail to: Kansas Department of Health & Environment

CLEAR FORM

1000 SW Jackson Suite 330

Topeka KS 66612-1365

(785)296-1688

1. Reporting Period

Important: Read all instructions before completing form

From January 1 to December 31, __________

Page ___1___ of ______

2. Facility Identification

2a. New Facility

Yes

3a. Owner/Operator Identification

Name __________________________________________________________________

Business Name ___________________________________________________________

Street Address___________________________________________________________

Address________________________________________________________________

Latitude_______________________ Longitude _________________________________

City_____________________ State__________________ Zip____________________

Section________________ Township_________________ Range ___________________

Business Phone_____________________________ Country_______________________

City___________________ County________________ State KS Zip______________

Submitter______________________________________________________________

Phone______________________________________ NAICS____________

Email __________________________________________________________________

Max # of occupants __________

Manned

Unmanned

Dun & Bradstreet_________________________________________________________

RMP Fac ID ____________________

N/A

3b. Mailing Address if different from Owner/Operator Address

TRI Fac ID ____________________

N/A

Business Name ___________________________________________________________

Address________________________________________________________________

Subject to Emergency Planning under Section 302 of EPCRA (40 CFR part 355)?

City_____________________ State__________________ Zip____________________

Yes

ATTN__________________________________________________________________

Phone__________________________________________________________________

Subject to Chemical Accident Prevention under Section 112r of CAA (40 CFR part 68)?

Yes

Please check as appropriate

4a. Tier II Contact

5. Section Reporting:

Name________________________________ Title______________________________

Section 312

Section 311

Section 302

Phone _____________________________24-hour Phone__________________________

Email___________________________________________________________________

Annual

Revision

Identical to last year

4b. Emergency Contact

For Official Use Only

Name________________________________ Title______________________________

Phone _____________________________24-hour Phone__________________________

Facility ID #

Parent ID #

Entered by

Email___________________________________________________________________

6. Optional Attachments

Name________________________________ Title______________________________

Phone _____________________________24-hour Phone__________________________

Site Plan

Description of Dikes

Email___________________________________________________________________

Site Coordinate Abbreviations

Other Safeguard Measures

7. 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 based on my inquiry of those individuals responsible

for obtaining this information, I believe the submitted information is true, accurate, and complete.

______________________________________________________

_____________________________

__________________________________________________

Name and official title of owner/operator or authorized representative

Date

Signature