NONCONFIDENTIAL LOCATION INFORMATION State Form 52015 (5-05) Indiana Department of Environmental Management Indiana Emergency Response Commission Page Read Instruction found after this form before completing this form. Reporting Period: From January 1 to December 31, _____ Facility Identification Tier II (From Mailing Label) Name _____________________________________________________ Phone ( Name _________________________________________________________ County ___________________________________ ZIP _________ E-mail ________________________________ Emergency Contact Name ______________________________________________________ Title _________________________________ SIC Code: ________________________________ Dunn & Bradstreet: __________________________________ CAS__________________________________ Inventory Pure Mix Solid 24-Hr. Phone ( ) _______________________________ Sudden Release of pressure 24-Hr. Phone ( ) _______________________________ Storage Codes and Locations (Nonconfidential) Storage Location ______ Max. Daily Amount (Code) ______ Avg. Daily Amount (Code) Reactivity Chem. Name__________________________ Fire Trade Secret ) ___________________________________ Temperature Health Hazards ) ___________________________________ Phone ( Date Received _____________________________ Physical and Phone ( Name _______________________________________________________ Title _________________________________ OFFICIAL USE ONLY (DO NOT FILL) Chemical Description ) ___________________________ Mailing Address ____________________________________________________________________________________ Street Address ___________________________________________ City __________________________________ Pressure Specific Information by Chemical Facility ID # _______________________________ Owner/Operator Name (Mailing Address) Container Type EMERGENCY AND HAZARDOUS CHEMICAL INVENTORY Check all that Apply: Check if information below is identical to the information submitted last year Optional Important: Read all instructions before completing form. of ______ No. of Days On-site (Days) Liquid Gas EHS Immediate (acute) EHS Name __________________________________ Delayed (chronic) CAS ________________________________ Fire ______ Max. Daily Amount (Code) Sudden Release of pressure ______ Avg. Daily Amount (Code) Reactivity ______ No. of Days On-site (Days) Chem. Name _________________________ Trade Secret Check all that apply: Pure Mix Solid Liquid Gas EHS EHS Name ___________________________________ Immediate (acute) Delayed (chronic) Optional Attachments Certification: Read and sign after completing all sections I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages 1 through ____, And that, based on my inquiry of those individuals responsible for obtaining the information, I believe the submitted information is true, accurate, and complete. I have attached a site plan I have attached a list of the site coordinate abbreviations _____________________________________________________________________________ Name and official title of owner/operator OR authorized representative __________________________________________ Signature __________________ Date signed I have attached a description of dikes and other safeguards American LegalNet, Inc. www.FormsWorkflow.com CONFIDENTIAL LOCATION INFORMATION State Form 52015 (5-05) Indiana Department of Environmental Management Indiana Emergency Response Commission Page Read Instruction found after this form before completing this form. Important: Read all instructions before completing form. Specific Information by Chemical Check if information below is identical to the information submitted last year Facility Identification Tier II EMERGENCY AND HAZARDOUS CHEMICAL INVENTORY Reporting Period: From January 1 to December 31, ____ Facility ID # _______________________________ of Owner/Operator Name (Mailing Address) (From Mailing Label) Name _________________________________________________________ Name _____________________________________________________ Phone ( ) __________________________ Mailing Address ___________________________________________________________________________________ Street Address ___________________________________________ City __________________________________ Emergency Contact County ___________________________________ ZIP _________ E-mail ________________________________ Name ______________________________________________________ Title ________________________________ Phone ( OFFICIAL USE ONLY (DO NOT FILL) Name _______________________________________________________ Title ________________________________ Date Received _____________________________ Phone ( ) ___________________________________ 24-Hr. Phone ( 24-Hr. Phone ( ) _______________________________ ) _______________________________ Storage Codes and Locations (Confidential) Storage Location Optional Temperature ) ___________________________________ Pressure Chemical Description Container Type SIC Code: ________________________________ Dunn & Bradstreet: __________________________________ CAS # ______________________________________________ Chemical Name ______________________________________ CAS # _____________________________________________ Chemical Name ________________________________________ Optional Attachments Certification: Read and sign after completing all sections I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages 1 through ____, And that, based on my inquiry of those individuals responsible for obtaining the information, I believe the submitted information is true, accurate, and complete. I have attached a site plan I have attached a list of the site coordinate abbreviations _____________________________________________________________________________ Name and official title of owner/operator OR authorized representative __________________________________________ Signature __________________ Date signed I have attached a description of dikes and other safeguards American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS 312 REPORTING (TIER II) A facility required to prepare or have available MSDSs for hazardous chemicals/substances under OSHA must prepare and submit an emergency and hazardous chemical inventory form (Tier II). The types of chemicals and the requirements for reporting are (i) hazardous chemicals that are stored in excess of 10,000 pounds and (ii) EHSs stored in excess of 500 pounds or the TPQ, whichever is smaller. This is an annual reporting requirement due by March 1 of each year and must be sent to the SERC c/o IDEM, appropriate LEPC, and local fire department at the following: • IDEM Indiana Emergency Response Commission Attn: Tier II 100 N. Senate Ave. Indianapolis, IN 46204 • LEPC—County where the facility is located • Local Fire Department—County where the facility is located 1. Pagination—Indicate the number of pages in the submission. If the submission includes 3 Tier II forms, pagination should be 1 of 3; 2 of 3; and 3 of 3. Pagination should be for only Tier II forms and not any optional attachments. 2. Reporting Period—Enter the reporting year. This is the previous year during which the chemicals being reported were stored at the facility. If reporting for a period greater than one year, each reporting year must be accurately recorded. If this space is left blank, the form will be returned. 3. Previously Submitted Tier II Query—Check this box if current facility information is that same as information submitted last years. 4. Facility ID Number—Provide the facility identification number for the facility. If the facility ID number is unknown, please refer to the IDEM CRTK web page for contact information. If this is a new facility or a first-time filer, indicate this in the designated space. If this space is left blank, the form will not satisfy the reporting requirements. 5. Name of the Facility—Enter the actual name of the facility, generally the name appearing on an exterior sign at the facility. If the facility does not have an official name, use a descriptive name. If this space is left blank, the form will not satisfy the reporting requirements. 6. Street Address—Provide the complete street address of the facility, including number, name, and type of roadway. A descriptive address or express delivery address, consisting of the name of the street and the distance from and name of the next nearest cross street, may be used. Providing only post office box numbers, railroads, routes, or highways is UNACCEPTABLE. If this space is left blank, the form will not satisfy the reporting requirements. 7. City—Provide the name of the city in which the facility is located. If the facility is remotely located, the name of the closest city, the city in which the primary responding fire department is located, or the township in which the facility is located must be provided. If this space is left blank, the form will not satisfy the reporting requirements. 8. County—Provide the name of the county in which the facility is located. This must be consistent with the location of the city. 9. ZIP Code—Provide either the 5- or 9-digit zip code for the facility. If the facility is remotely located, provide the zip code of the post office that serves the area. 10. E-mail—Enter the facility’s e-mail address. 11. Standard Industrial Classification (SIC) Code—Provide the 4-digit SIC code for the facility. This is a federal identification code indicating the type of business conducted by the facility and can be found on the facility’s tax forms. This code also can be found in the SIC code manual available at most libraries. 12. Dun & Bradstreet Number—Enter the facility’s Dun & Bradstreet number. The finance or accounting department can provide this number. Contact a local office of Dun & Bradstreet to obtain the facility’s number if this number is unknown. American LegalNet, Inc. www.FormsWorkflow.com 13. Owner/Operator Information—The SERC considers the person filing this form to be the owner/operator of the facility. 14. Emergency Contact Information—Provide the name, title, business or daytime phone numbers, and 24 hour contact number for both a primary and alternate emergency contact person. All persons named must be affiliated with the facility. Do not list the names and numbers of local emergency personnel. The emergency contact information is mandatory. If this space is left blank, the form will not satisfy the reporting requirements. 15. Chemical Abstract Service (CAS) —Provide the CAS number listed on the MSDS for each substance or mixture. The CAS number of some mixtures may not be specific or listed; therefore, a facility may do one of the following: a. Provide the CAS number for the mixture or the CAS numbers for the individual chemical components of the mixture. b. Provide the CAS number for the hazardous component which makes up the largest percent of the mixture or the CAS number of the most hazardous component of the mixture. c. Leave the space blank if the substance/mixture is diesel or fuel oil. 16. Chemical Name—Provide the common name or trade name of each substance or mixture stored at the facility. Mark the appropriate boxes corresponding to the physical and chemical properties of each named chemical. If the chemical is a designated EHS, mark the EHS box. 17. EHS Name—Provide the EHS name if the substance/mixture is an EHS or contains an EHS. 18. Physical and Health Hazards—A facility must have an MSDS for a substance designated as an OSHA hazardous substance. EPA has consolidated OSHA’s hazard categories into health and physical health hazards. The following chart shows the relationship between the OSHA and EPA hazard categories. A facility should review the MSDS for each substance. If the MSDS lists any of the OSHA hazards in the left column of this chart, find the corresponding EPA hazard on the right, and mark the appropriate box on this form. OSHA HAZARD CATEGORIES EPA HAZARD CATEGORIES Combustion Liquid Fire Pyrophoric Oxidizer Compressed Gas Explosive Sudden Release of Pressure Organic Peroxide Unstable-Reactive Reactive Physical Health Hazards Flammable Water-Reactive Highly Toxic Irritant Sensitizer Immediate (Acute) Corrosive Other adverse effects with short-term exposure Carcinogen Other adverse effects with long-term exposure Health Hazards Toxic Delayed (Chronic) American LegalNet, Inc. www.FormsWorkflow.com 19. Inventory Code—Enter the inventory code of each chemical/substance rather than the actual weight of the chemical. The inventory code represents a range based on the daily maximum weight of the chemical stored. The following is a list of inventory codes and the corresponding chemical weight ranges. INVENTORY CODE WEIGHT RANGES (POUNDS) INVENTORY CODE WEIGHT RANGES (POUNDS) 01 0–99 07 10,000,000–49,999,999 02 100–999 08 50,000,000–99,999,999 03 1,000–9,999 09 100,000,000–499,999,999 04 10,000–99,999 10 500,000,000–999,999,999 05 100,000–999,999 11 1 billion–greater than 1 billion 06 1,000,000–9,999,999 — — a. If a facility does not (i) store any EHS in a quantity greater than or equal to either the established TPQ or 500 pounds, whichever is less, or (ii) have any hazardous chemical/substance with an inventory code larger than 03, the facility is not subject to Tier II filing. b. If liquids are being reported, quantities must be converted to pounds by using one of the following (the density or specific gravity of the chemical will be listed on its MSDS): • • c. 20. density * number of gallons = pounds specific gravity * 8.3 * number of gallons = pounds If a hazardous substance was stored in excess of the minimum threshold level for even one day during the reporting year, the chemical/substance must be reported. Container Type and Storage Conditions—Enter the correct codes for container type, pressure, and temperature of each hazardous chemical/substance listed. If storing a chemical in several different container types, enter the code for each type of container and each applicable storage condition. Storage condition is ambient if the container is not heated, cooled, pressurized, or under vacuum. The following is a list of storage container types, temperature and pressure conditions, and their corresponding codes: STORAGE CONTAINER TYPES CODE STORAGE CONTAINER TYPES CODE TEMPERATURE AND PRESSURE CONDITIONS CODE Above-Ground Tank A Bag J Ambient Pressure 1 Below-Ground Tank B Box K Elevated Pressure 2 Tank Inside Building C Cylinder L Decreased Pressure or Vacuum 3 Steel Drum D Glass Bottles or Jugs M Ambient Temperature 4 Plastic or Non-Metal Drum E Plastic Bottles or Jugs N Elevated Temperature (heated) 5 Can F Tote Bin O Decreased Temperature (cooled) 6 7 Carbouy G Tank Wagon P Cryogenic Conditions (super-cooled) Silo H Rail Car Q — Fiber Drum I Other R — American LegalNet, Inc. www.FormsWorkflow.com 21. Storage Location—Enter a description of where the chemical is stored using the following guidance (“on site” and other such general descriptions are UNACCEPTABLE): a. If the chemical is stored outside, enter the size of the container and its location relative to buildings and roads. b. If the chemical is stored inside, provide the location relative to walls, doors, and other obvious structures inside the building. c. If the chemical is stored in many locations throughout the building, enter “ubiquitous.” d. If a site plan is provided, enter “see site plan.” However, the site plan must provide enough detail to locate easily the storage area of each chemical listed. The site plan must also include tank sizes, labeled streets, marked distances between structures, and any other information necessary to help emergency personnel quickly assess the site in the event of an emergency. e. If the “see site plan” option is chosen, provide a site plan even if one was submitted the previous year. f. If a detailed storage location is recorded on the Tier II form itself, submitting a site plan is optional. g. If chemical location confidentiality is being claimed for proprietary or competitive reasons, a facility must submit Tier II form mark the Confidential Location Information Sheet in addition to nonconfidential Tier II form. Do not submit the confidential location information sheet if you have disclosed storage location information on the nonconfidential Tier II form. Include the confidential location information sheet only if you wish to have storage locations kept from public view. When compiling the Tier II forms for submission, a facility must separate the non-confidential location sheet(s) from the Confidential Location Information Sheet(s). The SERC will, upon receipt, sort the information and placed the non-confidential Tier II form(s) in the public files while the confidential location information sheet(s) will be placed in a “not for public view” area. If a site plan is attached, it will be placed with the confidential information. h. Optional Attachments—Check all that apply. i. Certification Name and Official Title—Enter the name and title of the person authorized to certify the Tier II submission for the facility. If this space is left blank, the form will not satisfy reporting requirements. j. Certification Signature—Sign the form. This must be the original signature of the owner or authorized personnel. If this space is left blank, the form will not satisfy the reporting requirements. k. Certification Date of Signature—Enter the date on which the Tier II form was signed. If this space is left blank, the form will not satisfy the reporting requirements. American LegalNet, Inc. www.FormsWorkflow.com