Form 9350-2 Form A

Form Approved OMB Number: 2070-0143
(IMPORTANT: Type or print; read instructions before completing form)

EPA

Page 1 of

Approval Expires: 01/31/2008

TOXICS CHEMICAL RELEASE INVENTORY

United States
Environmental Protection Agency

FORM A

WHERE TO SEND COMPLETED FORMS: 1. TRI Data Processing Center
2. APPROPRIATE STATE OFFICE
P. O. Box 1513
(See instruction in Appendix E)
Lanham, MD 20703-1513
ATTN: TOXIC CHEMICAL RELEASE INVENTORY

Enter “X” here if
this is a revision
For EPA use only

IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.

PART 1. FACILITY IDENTIFICATION INFORMATION
SECTION 1. REPORTING YEAR
SECTION 2. TRADE SECRET INFORMATION
Are you claiming the toxic chemical identified on page 2 trade secret?

2.1

No (Do not answer 2.2; 2.2 Is this copy
Sanitized
Go to Section 3)
(Answer only if “YES” in 2.1)

Yes (Answer question 2.2;
Attach substantiation forms)

SECTION 3. CERTIFICATION

Unsanitized

(Important: Read and sign after completing all form sections.)

I hereby certify that to the best of my knowledge and belief, for each toxic chemical listed in the statement, the annual reportable amount as defined in 40 CFR
372.27 (a), did not exceed 500 pounds for this reporting year and that the chemical was manufactured, processed, or otherwise used in an amount not exceeding 1
million pounds during this reporting year.
Name and offical title of owner/operator or senior management official:

Signature:

Date Signed:

SECTION 4. FACILITY IDENTIFICATION
4.1
Facility or Establishment Name

TRI Facility ID Number
Facility or Establishment Name or Mailing Address (If different from street address)

Street

Mailing Address

City/County/State/Zip Code

City/State/Zip Code

Country (Non-US)

4.2 This report contains information for: (Important: Check c or d if applicable)
c.

4.3

A Federal
facility

GOCO

d.

Telephone Number (include area code)

Technical Contact Name
Email Address

4.4 Intentionally left blank
4.5 NAICS Code (s)

Primary

(6 digits)

a.

Dun & Bradstreet

a.

4.7 Number (s) (9 digits)

b.

c.

b.

SECTION 5. PARENT COMPANY INFORMATION
5.1 Name of Parent Company
5.2

NA

Parent Company’s Dun & Bradstreet Number

NA

EPA Form 9350 -2 (Rev. 08/2006) - Previous editions are obsolete.

d.

e.

f.

Page

(IMPORTANT: Type or print; read instructions before completing form)

EPA FORM A
PART II. CHEMICAL IDENTIFICATION

of

TRIFID:

Do not use this form for reporting PBT chemicals including Dioxin and Dioxin-like Compounds*

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.1

1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
1.3 Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY

(Important: DO NOT complete this section if you completed Section 1 above)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.1

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.2

Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

1.3

SECTION 2. MIXTURE COMPONENT IDENTITY

(Important: DO NOT complete this section if you completed Section 1 above)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

2.1

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.1
1.2
1.3

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

(Important: DO NOT complete this section if you completed Section 1 above.)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

SECTION 1. TOXIC CHEMICAL IDENTITY

Report

of

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.1
1.2

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

1.3

SECTION 2. MIXTURE COMPONENT IDENTITY
2.1

(Important: DO NOT complete this section if you completed Section 1 above.)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces, and punctuation.)

*See the TRI Reporting Fomrs and Instructions Manual for the list of PBT Chemicals (including Dioxin and Dioxin-like Compounds)
EPA Form 9350 -1 (Rev. 08/2006) - Previous editions are
obsolete.

(Make additional copies of this page, if needed)