Tier Two
EMERGENCY
AND
HAZARDOUS
CHEMICAL
INVENTORY
Specific
Information
by Chemical
Facility Identification
(2a)
Name __________________________________________________________
Street _________________________________________________________
City _________________ County ____________ State ______ Zip ________
SIC CODE
Dun & Bradstreet Number
FOR
OFFICIAL
USE
Owner/Operator Name
(2b)
Name _________________________Phone (_____) __________
Mail Address __________________________________________
Emergency Contact
(2c)
Name _________________________
Phone (_______)_______________
Name _________________________
Phone (_______)_______________
Title _________________
24 Hr. Phone _________
Title _______________
24 Hr. Phone ________
Important: Read all instructions before
completing form
Reporting Period (2d) From January 1 to December 31, 19_________
Check if information below is identical to the information
submitted last year.
(3)
Chemical Description
(4)
Physical
and Health
Hazards
(5)
Inventory
(6)
Storage Codes and Locations
(Non-Confidential)
Storage Locations
CAS
---
---
Trade Secret
Chem. Name ______________________________
Check at
that Apply
Pure
Mix
Solid
Liquid
Gas
EHS
EHS Name _________________________________
Fire
Sudden Release
of Pressure
Reactivity
Immediate (Acute
Delayed(Chronic)
Delayed(Chronic)
Certification (Read and sign after completing all sections.)(7)
I certify under penalty of law that I have personally examined and am familar 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 owner/operator OR owner/operator's authorized representative
_________________
Signature________Date Signed
I have attached a site plan
I have attached a list of site coordinate abbreviations
I have attached a description of dikes and other safeguard measures