Epa Emergency And Hazardous Chemical Inventory
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1
2
Check if information below is identical to the information submitted last year.
Reporting Period: January 1 to December 31, 20____
Tier Two
For Official Use Only
State ID#:
Emergency and Hazardous Chemical Inventory
Date Received
Specific Information by Chemical
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
Yes
No
Subject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68, Risk Management Program)?
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
Reporting Ranges
Certification (Read and sign after completing all sections)
Weight Range in pounds
Range Code
From
To
I certify under penalty of law that I have personally examined and
01
0
99
am familiar with the information submitted in pages one through
02
100
499
, and that based on my inquiry of those individuals responsible for
03
500
999
obtaining the information, I believe that the submitted information is
04
1,000
4,999
true, accurate and complete.
05
5,000
9,999
06
10,000
24,999
07
25,000
49,999
08
50,000
74,999
Name and official title of owner/operator OR owner/operator’s
09
75,000
99,999
authorized representative
10
100,000
499,999
11
500,000
999,999
Signature
Date Signed
12
1,000,000
9,999,999
13
10,000,000
Greater than 10 million
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 ___
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