Tier II
Emergency and Hazardous Chemical Inventory
Reporting Period January 1 to December 31 *
Facility Name *
Your answer
Facility Maximum # of Occupants *
Your answer
Manned or Unmanned *
Required
Facility Street Address *
Your answer
Facility County *
Facility City *
Zip Code
Your answer
Latitude and Longitude *
Your answer
NAICS Code
Your answer
Phone Number *
Your answer
DUN and Bradstreet Number *
Your answer
TRI Facility Number
Your answer
RMP Facility ID
Your answer
Subject to Emergency Planning Section 302 of EPCRA (40 CFR part 355)? *
Subject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68)? *
Owner/Operator Name, Address, and Phone Number *
Your answer
Facility Emergency Coordinator Name *
Your answer
Title
Your answer
Phone Number *
Your answer
24-hour emergency number *
Your answer
Tier II Information Contact Name and Phone Number *
Your answer
Emergency Contact 1 Name and 24-Hour Phone Number *
Your answer
Emergency Contact 2 Name and 24-Hour Phone Number *
Your answer
I certify by typing my name that I have personally examined and am familiar with the information submitted in this report and that based on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. *
Your answer
Title *
Your answer
Date *
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