Form 9350-1 Form R

United States

Environmental Protection Agency

FORM R

Section 313 of the Emergency Planning and Community

Right-to-Know Act of 1986, also Known as Title III of the

Superfund Amendments and Reauthorization Act

WHERE TO SEND COMPLETED FORMS:

1. TRI Data Processing Center 2. APPROPRIATE STATE OFFICE

P. O. Box 1513

(See instructions in Appendix E)

Lanham, MD 20703-1513

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

2.1

Are you claiming the toxic chemical identified on page 2 trade secret?

Yes (Answer question 2.2;

Attach substantiation forms)

No (Do not answer 2.2;

Go to Section 3)

2.2

Is this copy

Sanitized

Unsanitized

(Answer only if “YES” in 2.1)

SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)

I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the submitted information is true and

complete and that the amounts and values in this report are accurate based on reasonable estimates using data available to the preparers of this report.

Name and official title of owner/operator or senior management official:

Signature

:

Date Signed:

SECTION 4. FACILITY IDENTIFICATION

4.1

TRI Facility ID Number

Facility or Establishment Name

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

Street

Mailing Address

City/State/Zip Code

Country (Non-US)

4.2

This report contains information for:

(Important: Check a or b; check c or d if applicable)

b.

An entire

facility

Part of a

facility

c.

A Federal

facility

d.

GOCO

4.3

Technical Contact Name

Telephone Number (include area code)

4.4

Telephone Number (include area code)

4.5

NAICS Code (s)

(6 digits)

Primary

a. b. c. d. e. f.

4.6

Dun & Bradstreet

Number (s) (9 digits)

SECTION 5. PARENT COMPANY INFORMATION

5.1

5.2

Name of Parent Company

Parent Company’s Dun & Bradstreet Number

NA

NA

EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.

Email Address

Public Contact Name

City/County/State/Zip Code

TRI Facility ID Number

Toxic Chemical, Category or Generic Name

EPA

Form Approved OMB Number: 2070-0093

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

Approval Expires: 03/31/2011

Page 1 of 5

a.

b.

Withdrawal (enter up to two code(s))

Revision (enter up to two code(s))

a.

This section only applies if you are

revising or withdrawing a previously

submitted form, otherwise leave blank.

Email Address

Form Approved OMB Number: 2070-0093

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

Approval Expires: 03/31/2011

Page 2 of 5

FORM R

PART II. TOXIC CHEMICAL RELEASE INVENTORY REPORTING FORM

2.1

SECTION 3. ACTIVITIES AND USES OF THE TOXIC CHEMICAL AT THE FACILITY

(Important: Check all that apply.)

4.1

EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.

TRI Facility ID Number

Toxic Chemical, Category or Generic Name

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 1. TOXIC CHEMICAL IDENTITY

(

Important: DO NOT complete this section if you completed Section 2 below.)

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.)

3.1

Manufacture the toxic chemical:

3.2

Process the toxic chemical:

Otherwise use the toxic chemical:

3.3

Produce

a.

b.

Import

If produce or import

c.

d.

e.

f.

For on-site use/processing

For sale/distribution

As a byproduct

As an impurity

a .

b.

c.

d.

e.

As a reactant

As a formulation component

As an article component

Repackaging

As an impurity

a.

b.

c.

As a chemical processing aid

As a manufacturing aid

Ancillary or other use

SECTION 4. MAXIMUM AMOUNT OF THE TOXIC CHEMICAL ON SITE AT ANY TIME DURING THE CALENDAR YEAR

(Enter two digit code from instruction package.)

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ONSITE

A. Total Release

(pounds/year*)

(Enter a range code** or estimate)

B. Basis of Estimate

(enter code)

C. % From Stormwater

5.1

Fugitive or non-point

air emissions

NA

5.2

Stack or point

air emissions

NA

5.3

Discharges to receiving streams or

water bodies (enter one name per box)

Stream or Water Body Name

5.3.1

5.3.2

5.3.3

If additional pages of Part II, Section 5.3 are attached, indicate the total number of pages in this box

and indicate the Part II, Section 5.3 page number in this box.

(example: 1,2,3, etc.)

*For Dioxin or Dioxin-like compounds, report in grams/year.

** Range Codes: A= 1-10 pounds; B= 11-499 pounds; C= 500-999 pounds.

FORM R

PART II. CHEMICAL - SPECIFIC INFORMATION (CONTINUED)

EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.

TRI Facility ID Number

Toxic Chemical, Category or Generic Name

Page 3 of 5

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON SITE

(continued)

NA

A. Total Release

(pounds/year*) (enter range

code ** or estimate )

B. Basis of Estimate

(enter code)

5.4.1

5.4.2

5.5

5.5.1A

5.5.1B

Underground Injection onsite

to Class I Wells

Underground Injection onsite

to Class II-V Wells

Disposal to land onsite

RCRA Subtitle C landfills

Other landfills

5.5.2

5.5.3A

5.5.4

Land treatment/application

farming

RCRA Subtitle C

surface impoundments

Other disposal

SECTION 6. TRANSFERS OF THE TOXIC CHEMICAL IN WASTES TO OFF-SITE LOCATIONS

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS

(POTWs)

6.1.A Total Quantity Transferred to POTWs and Basis of Estimate

6.1.A.1

Total Transfers

(pounds/year*)

(enter range code ** or estimate)

6.1.A.2 Basis of Estimate

(enter code)

6.1.B

POTW Name

POTW Address

City

State

County

Zip

6.1.B

POTW Name

City

State

County

Zip

If additional pages of Part II, Section 6.1 are attached, indicate the total number of pages

in this box and indicate the Part II, Section 6.1 page number in this box (example: 1,2,3, etc.)

SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS

6.2.

Off-Site EPA Identification Number (RCRA ID No.)

Off-Site Location Name

Off-Site Address

City

State

County

Zip

Is location under control of reporting facility or parent company?

Country

(Non-US)

Yes

No

* For Dioxin or Dioxin-like compounds, report in grams/year

** Range Codes: A=1-10 pounds: B=1-499 pounds; C=500 - 999 pounds.

5.5.3B

Other surface impoundments

POTW Address

Form Approved OMB Number: 2070-0093

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

Approval Expires: 03/31/2011

Page 4 of 5

FORM R

PART II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete.

TRI Facility ID Number

Toxic Chemical, Category or Generic Name

SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS (CONTINUED)

A. Total Transfers

(pounds/year*)

(enter range code**or estimate)

B. Basis of Estimate

(enter code)

C. Type of Waste Treatment/Disposal/

Recycling/Energy Recovery

(enter code)

1.

2.

3.

4.

1.

2.

3.

4.

1.

2.

3.

4.

M

M

M

M

6.2

Off-Site EPA Identification Number (RCRA ID No.)

Off-Site Location Name

Off-Site Address

City

County

Zip

Country

(Non-US)

State

Is location under control of reporting facility or parent company?

Yes

No

A. Total Transfers

(pounds/year*)

(enter range code**or estimate)

B. Basis of Estimate

(enter code)

C. Type of Waste Treatment/Disposal/

Recycling/Energy Recovery

(enter code)

1.

2.

3.

4.

1.

2.

3.

4.

1.

2.

3.

4.

M

M

M

M

SECTION 7A. ON-SITE WASTE TREATMENT METHODS AND EFFICIENCY

Not Applicable (NA) -

Check here if no on-site waste treatment is applied to any

waste stream containing the toxic chemical or chemical category.

a. General

Waste Stream

[enter code]

b. Waste Treatment Method(s) Sequence

[enter 3- or 4- character code(s)]

d. Waste Treatment Efficiency

[enter 2 character code]

7A.1a

7A.1b

1

4

7

2

5

8

3

6

7A.1d

7A.2a

7A.2b

3

6

1

4

7

2

5

8

7A.3a

3

6

1

4

7

2

5

8

7A.4a

7A.3b

7A.4b

3

6

1

4

7

2

5

8

7A.5a

7A.5b

3

6

1

4

7

2

5

8

If additional pages of Part II, Section 6.2/7A are attached, indicate the total number of pages in this box

and indicate the Part II, Section 6.2/7 page number in this box:

(example: 1,2,3,etc.)

*For Dioxin or Dioxin-like compounds, report in grams/year

**Range Codes: A=1 - 10 pounds; B=11 - 499 pounds C= 500-999 pounds.

Form Approved OMB Number: 2070-0093

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

Approval Expires: 03/31/2011

7A.2d

7A.3d

7A.4d

7A.5d

FORM R

PART II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

EPA Form 9350 -1 (Rev. 08/2008) - Previous editions are obsolete. *For Dioxin or Dioxin-like compounds, report in grams/year.

TRI Facility ID Number

Toxic Chemical, Category or Generic Name

Page 5 of 5

SECTION

7B. ON-SITE ENERGY RECOVERY PROCESSES

Not Applicable (NA) -

Check here if no on-site energy recovery is applied to any waste

stream containing the toxic chemical or chemical category.

Energy Recovery Methods [enter 3-character code(s)]

2

3

SECTION 7C. ON-SITE RECYCLING PROCESSES

Not Applicable (NA) -

Check here if no on-site recycling is applied to any waste

stream containing the toxic chemical or chemical category.

Recycling Methods [enter 3-character code(s)]

1

2

3

SECTION 8. SOURCE REDUCTION AND RECYLING ACTIVITIES

Column A

Prior Year

(pounds/year*)

Column B

Current Reporting Year

(pounds/year*)

Column C

Following Year

(pounds/year*)

Column D

Second Following Year

(pounds/year*)

8.1

8.2

Quantity used for energy recovery

onsite

8.3

Quantity used for energy recovery

offsite

8.4

Quantity recycled

onsite

8.5

Quantity recycled offsite

8.6

Quantity treated onsite

8.7

Quantity treated offsite

8.8

Quantity released to the environment as a result of remedial actions, catastrophic events,

or one-time events not associated with production processes (pounds/year)*

8.9

Production ratio or activity index

8.10

Did your facility engage in any source reduction activities for this chemical during the reporting

year? If not, enter “NA” in Section 8.10.1 and answer Section 8.11.

Source Reduction Activities

[enter code(s)]

Methods to Identify Activity (enter codes)

8.10.1

a. b. c.

8.10.2

a. b. c.

8.10.3

a. b. c.

8.10.4

a. b. c.

8.11

Total on-site disposal to Class I

Underground InjectionWells, RCRA

Subtitle C landfills, and other landfills

Total other on-site disposal or other

releases

Total off-site disposal to Class I

Underground Injection Wells, RCRA

Subtitle C landfills, and other landfills

Total other off-site disposal or other

releases

8.1a

8.1b

8.1c

8.1d

1

Form Approved OMB Number: 2070-0093

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

Approval Expires: 03/31/2011

If you wish to submit additional optional information on source reduction, recycling, or pollution

control activities, check “Yes.”

Yes