TIER ONE INSTRUCTIONS
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Submission of thl« form Is required by Title III of the Superfund Amendments and Reauthorizatlon Act of
1986, Title III Section 312, Public Law 99-499, codified at 42 U.S.C. Section 11022.
CERTIFICATION
The owner or operator or the officially designated representative of the owner or operator must certify that at
Information Included In the Tier f submission Is true, accurate, and comptete. On the Tier f form, enter your fut
name and offtetal tttte. Sign your name and enter the current date. Also, enter the total number of pages In the
submission, Including all attachments.
The purpose of this form Is to provide State and local
officials and the public with Information on the general
types and locations of hazardous chemicals present at
your facility during the past year.
YOU MUST PROVIDE ALL INFORMATION
REQUESTED ON THIS FORM.
You may substitute the Tier Two form for this Tier
One form. (The Tier Two form provides detaBed
Information and must be submitted In response to
a specific request from State or local officiate.)
WHO MUST SUBMIT THIS FORM
Section 312 of Title III requires that the owner or opera-
tor of a facility submit this form If, under regulations Im-
plementing the Occupational Safety and Health Act of
1970, the owner or operator Is required to prepare or
have available Material Safety Data Sheets (MSOS) for
hazardous chemicals present at the facility. MSDS re-
quirements are specified In the Occupational Safety and
Health Administration (OSHA) Hazard Communication
•Standard, found In Title 29 of the Cqde of Federal Regu-
lations at §1910.1200.
This form does not have to be submitted If al of the
chemicals located at your facility are excluded under
Section 311 (e) of Title III or If the weight of each covered
hazardous chemical never equals or exceeds the mini-
mum threshold listed In Title III Section 312 during the
reporting year.
WHAT CHEMICALS ARE INCLUDED
You must report the Information required on this form for
every hazardous chemical for which you are required to
prepare or have available an MSDS under the Hazard
Communication Standard, unless the chemicals are ex-
' eluded under Section 311 (e) of Title III or they are below
the minimum reporting thresholds.
WHAT CHEMICALS ARE EXCLUDED
Section 311(e) of Title III excludes the following sub-
stances:
(I) Any food, food additive, color additive, drug, or
cosmetic regulated by the Food and Drug Admini-
stration:
(II) Any substance present as a solid In any manu-
factured Item to the extent exposure to the sub-
stance does not occur under normal conditions of
use;
(ill) Any substance to the extent It is used for per-
sonal, family, or household purposes, or is present in
the same form and concentration as a product pack-
aged for distribution and use by the general public:
(Iv) Any substance to the extent It is used In a re-
search laboratory or a hospital or other medical facu-
lty under the direct supervision of a technically quali-
fied Individual;
(v) Any substance to the extent It is used In routine
agricultural operations or Is a fertilizer held for sale
by a retaHer to the ultimate customer.
OSHA regulations. Section 1910.1200(b), stipulate ex-
emptions from the requirement to prepare or have avail-
able an MSDS.
REPORTING THRESHOLDS
Minimum thresholds have been established for Tier One/
Tier Two reporting under Title III, Section 312. These
thresholds are as follows:
For Extremely Hazardous Substances (EHSs) desig-
nated under section 302 of Title III, the reporting thresh-
old Is 500 pounds (or 227 kg.) or the threshold planning
quantity (TPQ), whichever Is lower;
For aN other hazardous chemicals for which facilities are
required to have or prepare an MSDS, the minimum re-
porting threshold Is 10.000 pounds (or 4.540 kg.).
You need to report hazardous chemicals that were pre-
sent at your facility at any time during the previous cal-
endar year at levels that equal or exceed these thresh-
olds. For Instructions on threshold determinations for
components of mixtures, see "What About Mixtures?"
on page 3 of these Instructions.
WHEN TO SUBMIT THIS FORM
Owners or operators of facilities that have hazardous
chemicals on hand In quantities equal to or greater than
set threshold levels must submit either Tier One or Tier
Two Forms by March 1.
WHERE TO SUBMIT THIS FORM
Send one completed Inventory form to each of the fol-
lowing organizations:
1. Your State emergency response commission
2. Your local emergency planning committee
3. The ftre department with jurisdiction over your
facility.
PENALTIES
Any owner or operator of a faculty who fails to submit or
supplies false Tier One information shall be Habte to the
United States for a civil penalty of up to $25,000 for each
such violation. Each day a violation continues shall con-
stitute a separate violation. In addition, any citizen may
commence a CM) action on his or her own behalf against
any owner or operator who fails to submit Tier One infor- .
mat ton.
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INSTRUCTIONS
Please read these instructions carefully. Print or type all responses.
You may u«e the Tier Two form as a worksheet for
completing Tier One. Fling In the Tier Two
chemical Information section should help you
assemble your Tier One responses.
If your responses require more than one page, fill in the
page number at the top of the form.
PHYSICAL AND HEALTH HAZARDS
Descriptions, Amounts, and Locations
This section requires aggregate information on chemi-
cals by hazard categories as defined In 40 CFR 370.2.
The two health hazard categories and three physical haz-
ard categories are a consolidation of the 23 hazard cate-
gories defined in the OSHA Hazard Communication Stan-
dard, 29 CFR 1910.1200. For each hazard type, indi-
cate the total amounts and general locations of all appli-
cable chemicals present at your facility during the past
year.
REPORTING PERIOD
Enter the appropriate calendar year, beginning January 1
and ending December 31.
FACILITY IDENTIFICATION
Enter the complete name of your facility (and company.
Identifier where appropriate).
Enter the full street address or state, road. If a street
address Is not available, enter other appropriate Identifi-
ers that describe the physical location of your facility
(e.g., longitude and latitude). Include city, county,
state, and zip code.
Enter the primary Standard Industrial Classification (SIC)
code and the Dun & Bradstreet number for your facility.
The financial officer of your facility should be able to pro-
vide the Dun & Bradstreet number. If your firm does not
have this Information, contact the State or regional of-
fice of Dun & Bradstreet to obtain your facility number or
have one assigned.
OWNER/OPERATOR
Enter the owner's or operator's full name, mailing ad-
dress, and phone number.
EMERGENCY CONTACT
Enter the name, title, and work phone number of at least
one local person or office that can act as a referral If
emergency responders need assistance In responding to
a chemical accident at the facility.
Provide an emergency phone number where such emer-
gency Information wW be available 24 hours a day, every
day. This requirement Is mandatory. The facility must
make some arrangement to ensure that a 24 hour con-
tact Is available.
Hazard Category Comparison
For Reporting Under Sections 311 and 312
EPA's
: Hazard Categories
5 ~~"~~"~"~~~~~^~^~~
\ Fire Hazard
:;;: Sudden Release of
j| Pressure
s;
I Reactive
;! Immediate (Acute)
s Health Hazards
'
Delayed (Chronic)
Health Hazard
OSHA's
Hazard Categories
Flammable
Combustion Uquld
Pyrophoric
Oxldizer
Explosive
Compressed Gas
Unstable Reactive
Organic Peroxide
Water Reactive
Highly Toxic
Toxic
Irritant
Sensitlzer
Corrosive
Other hazardous
chemicals with an
adverse effect with
short term exposure
.Carcinogens
Other hazardous
chemicals with an
adverse effect with
long term exposure
IDENTICAL INFORMATION
Check the box indicating Identical Information, located
below the emergency contacts on the Tier One form, If
the current information being reported Is identical to that
submitted last year. Chemical descriptions, amounts,
and locations must be provided in this year's form, even
if the Information Is Identical to that submitted last year.
What units should I use?
Calculate all amounts as weight in pounds. To
convert gas or liquid volume to weight- in
pounds, multiply by an appropriate density fac-
tor.
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INSTRUCTIONS
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Please read these instructions carefully. Print or type all responses.
What about mixtures?
If a chemical Is part of a mixture, you have the
option of reporting either the weight of the en-
tire mixture or only the portion of the mixture
that is a particular hazardous chemical (e.g., if
a hazardous solution weighs 100 Ibs. but is
composed of only 5% of a particular hazardous
chemical, you can indicate either 100 Ibs. of the
mixture or 5 Ibs. of the hazardous chemical).
The option used for each mixture must be con-
sistent with the, option used in your Section 311
reporting.
Because EHSs are important to Section 303
planning, EHSs have lower thresholds. The
amount of an EHS at a facility (both pure EHS
substances and EHSs In mixtures) must be ag-
gregated for purposes of threshold determina-
tion. It Is suggested that the aggregation calcu-
lation, be done as a first step in making the
threshold determination. Once you determine
whether a threshold has been reached for an
EHS, you should report either the total weight
of the EHS at your facility, or the weight of
•each mixture containing the EHS.
Where do I count a chemical that is a fire and
reactive physical hazard and an immediate
(acute) health hazard?
Add the chemical's weight to your totals for all
three hazard categories and include its location
in alt three categories. Many chemicals fall Into
more than one hazard category.
For each hazard type — beginning with Fire and re-
peating for all physical and health hazard types...
a. Add the maximum weights of all chemicals
you indicated as the particular hazard type.
b. Look at the Reporting Ranges at the bottom
of the Tier One form. Find the appropriate
range value code.
c. Enter this range value as the Maximum
Amount.
EXAMPLE:
You are using the Tier Two form as a
worksheet and have listed raw weights In pounds
for each of your hazardous chemicals. You
have marked an X In the Immediate (acute)
hazard column for phenol and sulfuric acid.
The maximum amount raw weight you listed
were 10,000 Ibs. and 500 Ibs. respectively. You
add these together to reach a total of 10,500 Ibs.
Then you look at the Reporting Range at the
bottom of your Tier One form and find that the
value of 04 corresponds to 10,500 Ibs. Enter
04 as your Maximum Amount for Immediate
(acute) hazards materials.
You also marked an X In the Fire hazard box
for phenol. When you calculate your
Maximum Amount totals for fire hazards,
add the 10,000 Ib. weight again.
MAXIMUM AMOUNT
The amounts of chemicals you have on hand may vary
throughout the year. The peak weights — greatest
single-day weights during the year — are added together
in this column to determine the maximum weight for each
hazard type. Since the peaks for different chemicals
often occur on different days, this maximum amount will
seem artificially high.
To complete this and the foRowfng sections, you may
choose to us* the Tier Two form at & worksheet.
To determine the Maximum Amount:
1. List aH of your reportable hazardous chemicals indl-
, vidually.
2. For each chemical...
a. Indicate all physical and health hazards that
the chemical presents. Include all chemicals,
even If they are present for only a short pe-
riod of time during the year.
b. Estimate the maximum weight In pounds that
was present at your facility on any single
day of the reporting period.
AVERAGE DAILY AMOUNT
This column should represent the average daHy amount
of chemicals of each hazard type that were present at or
above applicable thresholds at your facility at any point
during the year.
To determine this amount:
1. List aH of your reportable hazardous chemicals Indi-
vidually (same as for Maximum Amount).
2. For each chemical...
a. Indicate all physical and health hazards that
the chemical presents (same as for Maxi-
mum Amount).
b. Estimate the average weight In pounds that
was present at your facility throughout the •
year. To do this, total all daily weights and
divide by the number of days the chemical
was present on the site.
3. For each hazard type — beginning with Fire and
repeating for all physical and health hazards...
a. Add the average weights of all chemicals
you indicated for the particular hazard type.
b. Look at the Reporting Ranges at the bottom
of the Tier One form. Find -the appropriate
range value code.
c. Enter this range value as the Average Daily
Amount.
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INSTRUCTIONS
'' -•
Please read these instructions carefully. Print or type all responses.
EXAMPLE:
You are using the Tier Two form, and have
marked an X in the Immediate (acute) hazard
column for nicotine and phenol. Nicotine is
present at your facility 100 days during the year.
and the sum of the dally weights Is 100,000 Ibs.
By dividing 100,000 Ibs. by 100 days on-site.
you calculate an Average Daily Amount of
1,000 Ibs. for nicotine. Phenol is present at
your facility 50 days during the year, and the
sum of the daily weights Is 10,000 Ibs. By
dividing 10,000 Ibs. by 50 days on-site, you
calculate an Average Daily Amount of 200 Ibs.
for phenol. You then add the two average
daily amounts together to reach a total of
1,200 Ibs. Then you look at the Reporting
Range on your Tier One form and find that the
value 03 corresponds to 1,200 Ibs. Enter 03 as
your Average Daily Amount for Immediate
(acute) Hazard.
You also marked an X In the Fire hazard column
for phenol. When you calculate your Average
Daily Amount for fire hazards, use the 200 Ib.
weight again.
NUMBER OF DAYS ON-SITE
Enter the greatest number of days that a single chemical
within that hazard category was present on-slte.
GENERAL LOCATION
Enter the general location within your, facility where each
hazard may be found. General locations should Include
the names or identifications of buildings, tank fields, lots,
sheds, or other such areas.
For each hazard type, list the locations of all applicable
chemicals: As an alternative you may also attach a site
plan and list the site coordinates related to the appropri-
ate locations. If you do so, check the Site Plan box.
EXAMPLE:
On your worksheet you have marked an X In
the Fire hazard column for acetone and
butane. You noted that these are kept In steel
drums In Room C of the Main Building, and In
pressurized cylinders in Storage Shed 13,
respectively. You could enter Main Building
and Storage Shed 13 as the General
Locations of your fire hazards. However,
you choose to attach a site plan and list
coordinates. Check the Site Plan box at
the top of the column and enter site coor-
dinates for the Main Building and Storage Shed
13 under General Locations.
EXAMPLE:
At your facility, nicotine is present for 100 days
and phosgene is present for 150 days. Enter
150 in the space provided.
If you need more space to list locations, attach an addi-
tional Tier One form and continue your list on the proper
line. Number air pages.
CERTIFICATION
Instructions for this section are included on page one of
these Instructions.
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Revised June 1990
Page
of
pages
-,-. -. EMERGENCY AND HAZARDOUS
Tier One CHEMICAL INVENTORY
Aggregate Information by Hazard Type
Important: Read instructions before completing form
Form Approved OMB No. 2G5G-OQ7Z
POft
ONLY
Reporting Period
| 10*
'.•••••xffifi1 :-.-. • •ll<: > .: "••.-• •• • .•.•• •• • •• '
| Date Received
Name _
Street .
City
. County
State
SIC Code
J-l I M-LLLLJ
Name
Mail Address
Phone JL
L
From January 1 to December 31,19_
Erowgancy Cont«ct*
Name
Tltie
Phone _L
24 Hour Phone _L
Name
Title
Phone _L
24 Hour Phone _L
I | «kKft«fr
L—I *tormaS«i mbmSted iait yuan
Hazard Type
Average Number
Max Daily of Days
Amount" Amount* On-Site
General Location
Check if site plan is attached
Sudden Release I I 1 I I I
of Pressure I—I—I L—I—I
\ I I I
Reactivity fTI I~T~I I I I I
| Health Hazards |
Immediate i — i — i
(acute) 1 — 1 — 1
Delayed 1 T~~l
(Chronic) 1 — I_J
L_U
CD
II!
Ill
CerBficallon .
I eertSy under penalty o» law that I have personally examined and «m familar wtth
the information submlned in pages one through _ , and that based on my
inquiry of those individuals responsfcfe for obtaining the information, I believe that
the submitted InforrmDon is true, accurate and conpM*.
Name and official title of owner/operator OR owner/operators authorized representative
Signature
Date signed
Reporting Ranges
Weight Range in Pounds
From,.. To...
01 0
02 100
03 1000
04 10,000
05 100,000
06 1,000,000
07 fO.OOO.OOO
08 50,000,000
09 100,000,000
10 500,000,000
11 1 billion
99
999
9,999
99,999
999,999
9,999,999
49,999,999
99,999,999
499,999,999
999,999,999
higher than 1 billion
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