Facility Identification

Owner/Operator Name
 

Name

    

Name

  

Phone

( )

  

Tier Two

Street

    

Mail Address

    

EMERGENCY

City

  

County

  

State

  

Zip

      

AND

  

Emergency Contact

HAZARDOUS

SIC Code

  

Dun & Brad Number

      

CHEMICAL

  

Name

  

Title

    

INVENTORY

      

Phone

( )

24 Hr. Phone

( )

  
 

FOR

ID #

      

Specific

OFFICIAL

    

Name

  

Title

    

Information

USE

Date Received

    

Phone

( )

24 Hr. Phone

( )

  

by Chemical

ONLY

      
         

Important: Read all instructions before completing form

Reporting Period From January 1 to December 31, 19

    

[ ] Check if information below is identical to the information submitted last year.
         

 

Chemical Description

Physical

and Health

Hazards

(check all that apply)

 

Inventory

  

 

Storage Codes and Locations

(Non-Confidential)

 

Storage Locations

Trade

 		                   

CAS

  

Secret

    

[ ] Fire

Max. Daily

 		               

Chem. Name

    

[ ] Sudden Release

      

Amount (code)

                
     

of Pressure

                  

Check all

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ] Reactivity

      

Avg. Daily Amount

                

that apply

Pure

Mix

Solid

Liquid

Gas

EHS

[ ] Immediate (acute)

(code)

 		               

EHS Name

    

[ ] Delayed (chronic)

        

No. of Days

              

[ ]
       

On-site (days)

 		               
                     

Trade

 		                   

CAS

  

Secret

    

[ ] Fire

Max. Daily

 		               

Chem. Name

    

[ ] Sudden Release

      

Amount (code)

                
     

of Pressure

                  

Check all

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ] Reactivity

      

Avg. Daily Amount

                

that apply

Pure

Mix

Solid

Liquid

Gas

EHS

[ ] Immediate (acute)

(code)

 		               

EHS Name

    

[ ] Delayed (chronic)

        

No. of Days

              

[ ]
       

On-site (days)

 		               
                     

Trade

 		                   

CAS

  

Secret

    

[ ] Fire

Max. Daily

 		               

Chem. Name

    

[ ] Sudden Release

      

Amount (code)

                
     

of Pressure

                  

Check all

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ] Reactivity

      

Avg. Daily Amount

                

that apply

Pure

Mix

Solid

Liquid

Gas

EHS

[ ] Immediate (acute)

(code)

 		               

EHS Name

    

[ ] Delayed (chronic)

        

No. of Days

              

[ ]
       

On-site (days)

 		               
                     

Certification (Read and sign after completing all sections)

Optional Attachments

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

[ ] I have attached a site plan

on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.

[ ] I have attached a list of site coordinate abbreviations
             

[ ] I have attached a description of dikes and other
 

Name and official title of owner/operator OR owner/operator’s authorized representative

  

Signature

  

Date signed

  

safeguards measures