9350-1 Form R Schedule 1

Form Approved OMB Number:2070-0212
Approval Expires: 06/30/2025

Page 1 of 4
TRI Facility ID Number

FORM R Schedule 1
PART II. CHEMICAL-SPECIFIC INFORMATION

(continued)

SECTION 5. QUANTITY OF DIOXIN AND DIOXIN-LIKE COMPOUNDS ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE
5.1

NA

5.2

Fugitive or nonpoint air emissions

NA

5.3

Discharges to receiving streams or water bodies
(Enter data for one stream or water body per box)

Stack or point
air emissions

5.3.1

5.3.2

NA
5.3.3

1
D. Mass (grams) of each compound in the category (1-17)

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
If additional pages of Section 5.3 are attached, indicate the total number of pages in this box
and indicate the Section 5.3 page number in this box (Example: 1, 2, 3, etc.)

EPA Form 9350 -3 (Rev. 07/2020). Previous editions are obsolete.

See the Reporting Forms and Instructions for information
on submissions and the Paperwork Reduction Act.

Form Approved OMB Number:
2070-0212 Approval Expires: 06/30/2025

FORM R Schedule 1
PART II. CHEMICAL-SPECIFIC INFORMATION

Page 2 of 4
TRI Facility ID Number

(continued)

SECTION 5. QUANTITY OF DIOXIN AND DIOXIN-LIKE COMPOUNDS ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE
5.4 – 5.5 Disposal to land on-site
5.4.1

NA

Class I
Underground
Injection Wells

5.4.2

NA

Class II-V
Underground
Injection Wells

5.5.1.A

NA

RCRA Subtitle C
landfills

5.5.1.B

NA

Other landfills

5.5.2

NA

Land treatment/
application farming

5.5.3.A

NA

RCRA Subtitle C
surface
impoundments

5.5.3.B

NA

Other surface
impoundments

5.5.4

NA

Other disposal

1
C. Mass (grams) of each compound in the category (1-17)

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Paperwork Reduction Act
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-0212). Responses to this collection of
information are mandatory, as specified in 40 CFR 372. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 35.71 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 to the
Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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 9350 -3 (Rev. 07/2020). Previous editions are obsolete.

Form Approved OMB Number: 2070-0212
Approval Expires: 06/30/2025

FORM R Schedule 1
PART II. CHEMICAL-SPECIFIC INFORMATION

Page 3 of 4
TRI Facility ID Number

(continued)

SECTION 6. TRANSFERS OF DIOXIN AND DIOXIN-LIKE COMPOUNDS IN WASTES TO OFF-SITE LOCATIONS
6.1. DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs)
6.1 ___
1.
9
2.
9
3.
9
6.1 ___
1.
9
2.
9
3.
9

1
10
1
10
1
10

2
11
2
11
2
11

3
12
3
12
3
12

1
10
1
10
1
10

2
11
2
11
2
11

3
12
3
12
3
12

D. Mass (grams) of Each Compound in the Category (1-17)
4
5
6
13
14
15
4
5
6
13
14
15
4
5
6
13
14
15
D. Mass (grams) of Each Compound in the Category (1-17)
4
5
6
13
14
15
4
5
6
13
14
15
4
5
6
13
14
15

NA
7
16
7
16
7
16

8
17
8
17
8
17

7
16
7
16
7
16

8
17
8
17
8
17

6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS
6.2 ___
1.
9
2.
9
3.
9
6.2 ___
1.
9
2.
9
3.
9

1
10
1
10
1
10

2
11
2
11
2
11

3
12
3
12
3
12

1
10
1
10
1
10

2
11
2
11
2
11

3
12
3
12
3
12

D. Mass (grams) of Each Compound in the Category (1-17)
4
5
6
13
14
15
4
5
6
13
14
15
4
5
6
13
14
15
D. Mass (grams) of Each Compound in the Category (1-17)
4
5
6
13
14
15
4
5
6
13
14
15
4
5
6
13
14
15

If additional pages of Section 6.1 or 6.2 are attached, indicate the total number of pages in this box
and indicate the Section 6.1 or 6.2 page number in this box

EPA Form 9350 -3 (Rev. 07/2020). Previous editions are obsolete.

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

NA
7
16
7
16
7
16

8
17
8
17
8
17

7
16
7
16
7
16

8
17
8
17
8
17

Form Approved OMB Number: 2070-0212
Approval Expires: 06/30/2025

FORM R Schedule 1
PART II. CHEMICAL-SPECIFIC INFORMATION

Page 4 of 4
TRI Facility ID Number

(continued)

SECTIONS 8.1-8.8. WASTE MANAGEMENT QUANTITIES FOR DIOXIN AND DIOXIN-LIKE COMPOUNDS (current year only)
8.1-8.7 Production-related waste managed
8.1a
8.1b
8.1c
8.1d
8.2
8.3
8.4
8.5
8.6
Total on-site
Total other
Total off-site
Total other
Quantity used for Quantity used for Quantity recycled Quantity recycled Quantity treated
disposal to
on-site disposal
disposal to
off-site disposal energy recovery energy recovery
on-site
off-site
on-site
Class 1
or other releases
Class 1
or other releases
on-site
off-site
Underground
Underground
Injection Wells,
Injection Wells,
RCRA Subtitle C
RCRA Subtitle C
landfills, and
landfills, and
other landfills
other landfills

8.7
Quantity treated
off-site

Column f. Mass (grams) of each compound in the category (1-17)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
*Includes quantities released to the environment or transferred off-site as a result of remedial actions, catastrophic events, or other one-time events not associated with production processes.

EPA Form 9350 -3 (Rev. 07/2020). Previous editions are obsolete.

8.8 Non-production
related
waste managed*