ࡱ> RTQv7 .bjbjUU >7|7| 4l((((8`|(y<L8.$/ O!z3pp0 BD((ppI0yp!!p((Facility IdentificationOwner/Operator NameNameNamePhone( )Tier TwoStreetMail AddressEMERGENCYCityCountyStateZipANDEmergency ContactHAZARDOUSSIC CodeDun & Brad NumberCHEMICALNameTitleINVENTORYPhone( )24 Hr. Phone( )FORID #SpecificOFFICIALNameTitleInformationUSEDate ReceivedPhone( )24 Hr. Phone( )by ChemicalONLYImportant: Read all instructions before completing formReporting Period From January 1 to December 31, 19[ ] Check if information below is identical to the information submitted last year. Chemical Description Physical and Health Hazards (check all that apply) Inventory EMBED MSWordArt.2 \s  EMBED MSWordArt.2 \s  EMBED MSWordArt.2 \s  Storage Codes and Locations (Non-Confidential) Storage Locations EMBED MSWordArt.2 \s TradeCASSecret[ ] FireMax. DailyChem. Name[ ] Sudden ReleaseAmount (code) of PressureCheck all[ ][ ][ ][ ][ ][ ][ ] ReactivityAvg. Daily Amountthat applyPureMixSolidLiquidGasEHS[ ] Immediate (acute)(code)EHS Name[ ] Delayed (chronic)No. of Days[ ]On-site (days)TradeCASSecret[ ] FireMax. DailyChem. Name[ ] Sudden ReleaseAmount (code) of PressureCheck all[ ][ ][ ][ ][ ][ ][ ] ReactivityAvg. Daily Amountthat applyPureMixSolidLiquidGasEHS[ ] Immediate (acute)(code)EHS Name[ ] Delayed (chronic)No. of Days[ ]On-site (days)TradeCASSecret[ ] FireMax. DailyChem. Name[ ] Sudden ReleaseAmount (code) of PressureCheck all[ ][ ][ ][ ][ ][ ][ ] ReactivityAvg. Daily Amountthat applyPureMixSolidLiquidGasEHS[ ] Immediate (acute)(code)EHS Name[ ] Delayed (chronic)No. of Days[ ]On-site (days)Certification (Read and sign after completing all sections)Optional AttachmentsI certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through, and that based[ ] I have attached a site planon my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.[ ] I have attached a list of site coordinate abbreviations[ ] I have attached a description of dikes and otherName and official title of owner/operator OR owner/operators authorized representativeSignatureDate signedsafeguards measures PageofpagesForm Approved OMB No. 2050-0072 -./45;<BHJSZ[ijlv!&'*3<CDMY]klsylmnsu 56CJ5CJ5CJCJ56CJOJQJ56CJOJQJ55CJCJCJ5CJ5CJM-./456;<BHIp $dB$Ifa$ dB$IfU$$IfHF"U9   l \       4 Ha dB<$If -IJSZ7,! dB($If dB$If$$IfH V !"%%/l27U9  XD a Gzj $$$$4 HaZ[\ijklv{RII dB$If$$IfH֞V !"'7U9  XD j 4 Ha dB($If{| $dB$Ifa$ dB$If `$$IfH  BCtM!"U9  vFa7*D\   ,,,,4 Ha $dB$Ifa$U$$IfHF"U9  l\      4 Ha dB$If ]dTTTTHTT $dB$Ifa$ dB$If$$IfH֞d !"U9  Th\  4 Ha]THTTTT $dB$Ifa$ dB$If$$IfH֞"%.17U9  l  *8` 4 Ha dB$If $dB$Ifa$8 dB$If$$IfH !"%r,17U9  $ h F8`  ($$$$4 Ha!&'()*:$$IfHֈ!"U9  $ h\   24 Ha dB$If $dB$Ifa$*3<=>CDJKL $dB$Ifa$ $dB$Ifa$ dB$If LMY dB$If$$IfH !"%.17U9  $ h *+m  ($$$$4 HaY]klmsyTFf $dB$Ifa$ dB$If $dB$Ifa$h_S___ $d$Ifa$ d$If$$IfHr!"U9  $ h\   (4 Halh`U``EP$If^` $P$Ifa$P$If$$IfHr!"U9   $  h \    (4 HalmnopqrbYYYYHd$If^` d$If$$IfHr:!(##U9  hr   24 Harstub$YYYYYYYYY $$Ifa$$$IfHr:!(##U9    h  r    24 Ha :MN`{$If $$Ifa$ MN_`awxyz|bm|  . 5 ȿ}zzvvzszpzzCJCJ 6CJCJ j6 CJU"j6 OJQJUVmHnHu56CJOJQJ5j6 CJU"j6 OJQJUVmHnHuj6 CJU"j6 OJQJUVmHnHuj6 CJU"j6 OJQJUVmHnHuCJ jCJU,{|7D*! d`$If  d`$If^ $$IfH B"$ &<(Y*Y7U9  b  N           $$$$4 Ha $d`$Ifa$ d`$If $$IfH B"$ &<(Y*C+*6Y7U9 b N     . ,,,,4 HaFf $d`$Ifa$ d`$If^ d`$If      $(x@FfFfh d`$If $d`$Ifa$(,04DEFGYZ[\]^_`abmrv|@Ff& d`$If $d`$Ifa$FfV $d`$Ifa$ d`$If d`$If^         p0 Md$If^M d$IfFf Md`$If^MFf $d`$Ifa$ d`$If        d$If $d$Ifa$  D$$IfH B"$ &<(Y*C+*6Y7U9  b  N         -   ,,,,4 Ha   ! 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PPPP4 Ha$$IfHz*.26 : > B"$ &<(Y*C+*6Y7U9r b N   . DDDD4 Ha$$IfHzBt6"$ &<(Y*C+*6Y7U9& 2 2b    . DDDD4 Ha$$$IfH" B"$ &<(Y*C+*6Y7U9V  2b N   . 44444 Hap$$IfHN  4B"$ &<(S*C+*6Q7U9. v` P   ' <<<<4 Ha$$IfHd84Bt&"$ &<(Y*C+*6Y7U9  b    . @@@@4 Ha$$$IfH" 4B"$ &<(Y*C+*6Y7U9  \ b N   . 44444 Ha.$$IfHּ*.26 : > Bt6"$ &<(Y*C+*6Y7U9r b    . PPPP4 Ha$$IfHz*.26 : > B"$ &<(Y*C+*6Y7U9r b N   . DDDD4 Ha$$IfHzBt6"$ &<(Y*C+*6Y7U9& 2 2b    . DDDD4 Ha$$$IfH" B"$ &<(Y*C+*6Y7U9V  2b N   . 44444 Ha1Table!SummaryInformation(&DocumentSummaryInformation8@CompObjj Oh+'0  ( D P \ ht|Facility Identification 0aci Employee ofmplmplNormaleCindye4ndMicrosoft Word 9.0t@G@P@ P@f,  ՜.+,0 px  TVA  Facility Identification Title  FMicrosoft Word Document MSWordDocWord.Document.89q iH@H Normal5$7$8$9DH$OJQJ_HmH sH tH <A@< Default Paragraph Font,@, Header  !, @, Footer  !. 3333365 .#2IZ{*LYlr{(   ( ) > $ ` " H O P Y 2m . !"$%&'()*+,-./013456789:;<=>?@ABCDEFG-`wy. :::: , /  Sharon P. DixonC:\mydoc\WORDFRM\17314a.docSharon P. DixonC:\mydoc\WORDFRM\17318.docSharon P. DixonC:\mydoc\WORDFRM\17318.doc Employee of%C:\My Documents\EPA TIER TWO FORM.DOCCindy+C:\My Documents\SARA Title III\Tier II Form-./456;<BHIJSZ[\ijklv{|!&'()*3<=>CDJKLMY]klmsylmnopqrs`{|      $(,04DEFGYZ[\]^_`abmrv|      !"#$%&'()-.567ALMNOPQRSTU`abvwxy #'>EFGHIJKLMNWXYpqrst#$%&'()*+,-./@ABCDEFGHIJTX\`dhl|}~   !"#'()*+,;<=>?@ABCDEFGHIJKLMNOP& ' 8 Y Z / 0 1 2 3 4 5 6 7 m n o   / @NEC SuperScript GDINEC.GDISUMOGDINEC SuperScript GDINEC SuperScript GDIRg odXXXX22,C:\NECSSFW\DEFAULT.GDIC:\NECSSFW\PRINT.GDIC:\NECSSFW\PRINT.GDIC:\NECSSFW\OVERLAY.GDINEC SuperScript GDINEC SuperScript GDIRg odXXXX22,C:\NECSSFW\DEFAULT.GDIC:\NECSSFW\PRINT.GDIC:\NECSSFW\PRINT.GDIC:\NECSSFW\OVERLAY.GDINEC SuperScript GDI |d. @@UnknownG:Times New Roman5Symbol3& :Arial"0hf6bFg !xx0 Facility Identification Employee ofCindy