Form 9350-2 Form A TRI

DRAFT

Form Approved OMB Number: 2025-0009
Approval Expires: 10/31/

Page 1 of ___

TOXICS RELEASE INVENTORY
FORM A
TRI Facility ID Number

This section only applies if you are revising or withdrawing a
previously submitted form, otherwise leave blank.

Revision (Enter up to two code(s))

Withdrawal (Enter up to two code(s))

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

PART I. FACILITY IDENTIFICATION INFORMATION
SECTION 1. REPORTING YEAR _____________
SECTION 2. TRADE SECRET INFORMATION
Are you claiming the toxic chemical identified on page 2 as a trade secret?
2.1

Yes (Answer question 2.2;
attach substantiation forms)

SECTION 3. CERTIFICATION

2.2 Is this copy

No (Do not answer 2.2;
go to Section 3)

Sanitized
Unsanitized
(Answer only if “Yes” in 2.1)

(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 this 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 official title of owner/operator or senior management official:

Signature:

Date signed:

SECTION 4. FACILITY IDENTIFICATION
Facility or Establishment Name

TRI Facility ID Number

Physical Street Address

Mailing Address (if different from physical street address)

City/County/Tribe/State/ZIP Code

City/State/ZIP Code

4.1

4.2

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

c.

Technical Contact Name

Country (Non-US)

A Federal facility

d.

GOCO

Telephone Number (include area code and ext.)

4.3
Email Address
4.4

Public Contact Name

Telephone Number (include area code and ext.)

Email Address
Primary
4.5

NAICS Code(s) (6 digits)
a.

4.6

Dun & Bradstreet
Number(s) (9 digits)

b.

c.

d.

e.

f.

a.
b.

SECTION 5. PARENT COMPANY INFORMATION
5.1
5.2

Name of U.S. Parent Company
(for TRI Reporting purposes)
Parent Company’s Dun & Bradstreet Number

No U.S. Parent Company
(for TRI Reporting purposes)
NA

EPA Form 9350 -2 (Rev. 06/2014) - Previous editions are obsolete.

DRAFT

Form Approved OMB Number: 2025-0009
Approval Expires: 10/31/

EPA FORM A
PART II. CHEMICAL IDENTIFICATION

Page ___ of ___

TRI Facility ID Number

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
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
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
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
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
*See the TRI Reporting Forms and Instructions manual for the list of PBT Chemicals (including Dioxin and Dioxin-like Compounds)
EPA Form 9350 -2 (Rev. 06/2014) - Previous editions are obsolete.

(Make additional copies of this page, if needed)