Fillable Form 8700-30 Tier Two Emergency and Hazardous Chemical Inventory form

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Form 8700-30 Tier Two Emergency and Hazardous Chemical Inventory form

On average this form takes 30 minutes to complete

The Form 8700-30 Tier Two Emergency and Hazardous Chemical Inventory form form is 2 pages long and contains:

  • 1 signature
  • 70 check-boxes
  • 83 other fields

Country of origin: US
File type: PDF

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( )
Range Code From To
01 0 99
02 100 499
03 500 999
04 1,000 4,999
05 5,000 9,999
06 10,000 24,999
07 25,000 49,999
08 50,000 74,999
09 75,000 99,999
10 100,000 499,999
11 500,000 999,999
12 1,000,000 9,999,999
13 10,000,000 Greater than 10 million
Check
if
information
below
is
identical
to
the
information
submitted
last
year.
Reporting Period:
January 1 to December 31, 20
Tier
Two
Emergency and Hazardous Chemical Inventory
Specific Information by Chemical
For Official Use Only
State ID#:
Date Received
Facility Identification
Name
N/A
Maximum No. of Occupants:
Manned Unmanned
Street County City State Zip
Latitude Longitude NAICS Code Phone Number (optional)
( )
Dun & Bradstreet Number TRI Facility ID: RMP Facility ID:
N/A N/A
Subject to Emergency Planning under Section 302 of EPCRA (40 CFR part 355)?
Yes
No
Subject to Chemical Accident Prevention under Section 112(r) of CAA (40 CFR part 68, Risk Management Program)?
Yes
No
Owner or Operator Information Parent Company Information (optional)
Name Name Dun & Bradstreet Number:
Address A
ddress
Phone Nu
mber Email
( )
Phone Number Email
( )
Facility Emergenc
y Coordinator (if applicable) Tier
II
Information
Contact
Name T
itle Name Tit
le
Email Address Email Address
Phone Number 24-hour Phone
( ) ( )
Phone Number
Emergency
Contacts
Name Name
Title Title
Phone Number 24-hour Phone
( ) ( )
Phone Number 24-hour Phone
( ) ( )
Email Address Email Address
Certification (Read and sign after completing all sections)
Reporting
Ranges
Weight Range in
pounds
I certify under penalty of law that I have personally examined
and
am familiar with the information submitted in pages one
through
, 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.
Name and official title of o
wner/operator OR
owner/operator’s
authorized
representative
Signature Date Signed
The public reporting and recordkeeping burden for this collection of information is estimated to range from 6 to 120 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,
including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T),
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 No. 8700-30 OMB Control No. 2050-0072 Expiration Date: 3/31/2022
Page 1 of
click to sign
signature
click to edit
EPA Form No. 8700-30
OMB Control No. 2050-0072
Expiration Date: 3/31/2022 Page of
Chemical Description
Physical Hazards Health Hazards Inventory Type of Storage
Storage
Conditions
(Pressure,
Temperature)
Storage
Locations
Additional
Reporting
Information
(Optional)
Check if information below is
identical to the information
submitted last year.
Chemical Name:
CAS No.
EHS: Yes No
Solid Liquid Gas
Trade Secret
Explosive
Flammable (gases,
aerosols, liquids, or
solids)
Oxidizer (liquid, solid or
gas)
Self-reactive
Pyrophoric (liquid or solid)
Pyrophoric Gas
Self-heating
Organic peroxide
Corrosive to metal
Gas under pressure
(compressed gas)
In contact with water emits
flammable gas
Combustible Dust
Hazard Not Otherwise
Classified
Acute toxicity (any route of
exposure)
Skin corrosion or irritation
Serious eye damage or eye
irritation
Respiratory or skin
sensitization
Germ cell mutagenicity
Carcinogenicity
Reproductive toxicity
Specific target organ
toxicity(single or repeated
exposure)
Aspiration hazard
Simple Asphyxiant
Hazard Not Otherwise
Classified
Maximum Amount
Range Code:
Confidential:
Yes No
Below
Reporting
Thresholds
(optional)
State
or Local
Requirements
Average Daily
Amount
Range Code:
No. of days on site:
Check if information below is
identical to the information
submitted last year.
Mixture or Product Name:
CAS No.
Not Available
Solid Liquid Gas
Trade Secret
EHS: Yes No
Explosive
Flammable (gases,
aerosols, liquids, or
solids)
Oxidizer (liquid, solid or
gas)
Self-reactive
Pyrophoric (liquid or solid)
Pyrophoric Gas
Self-heating
Organic peroxide
Corrosive to metal
Gas under pressure
(compressed gas)
In contact with water emits
flammable gas
Combustible Dust
Hazard Not Otherwise
Classified
Acute toxicity (any route of
exposure)
Skin corrosion or irritation
Serious eye damage or eye
irritation
Respiratory or skin
sensitization
Germ cell mutagenicity
Carcinogenicity
Reproductive toxicity
Specific target organ
toxicity(single or repeated
exposure)
Aspiration hazard
Simple Asphyxiant
Hazard Not Otherwise
Classified
Maximum
Amount (Total
Mixture) Range
Code:
Confidential:
Yes No
Below
Reporting
Thresholds
(optional)
State
or Local
Requirements
Average Daily
Amount (Total
Mixture) Range
Code:
EHS(s) Name (if applicable):
CAS No.
No. of days on site:
Maximum Amount
of each EHS in the
Mixture
Range Code:
Non-EHS(s) Name (optional):
Optional Attachments: I have attached a list of site coordinate
abbreviations
I have attached a site plan
I have attached
a description
of dikes and other safeguard
measures
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Form 8700-30 Tier Two Emergency and Hazardous Chemical Inventory form

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Completed 23 February 2020

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