311 REPORTING State Form 52017 (R/1-07) Indiana Department of Environmental Management Indiana Emergency Response Commission Read Instruction found after this form before completing this form Page Facility ID # Name of facility: of Date: (month, day, year) Street Address (no P.O. boxes, please): City: County: Email: Please list the components (that require reporting) of mixtures as separate chemicals. Make additional copies of this form as needed in order to list all chemicals necessary. Chemical Name ZIP code: Physical and Health Hazards Type of chemical _______________________________ EHS __________________________________ CERCLA Fire CAS # OTHER Immediate (acute) __________________________________ EHS __________________________________ CERCLA Fire CAS # OTHER Immediate (acute) __________________________________ EHS __________________________________ CERCLA Fire CAS # OTHER Immediate (acute) __________________________________ EHS __________________________________ CERCLA Fire CAS # OTHER Immediate (acute) __________________________________ EHS __________________________________ CERCLA Fire CAS # OTHER Immediate (acute) __________________________________ EHS __________________________________ CERCLA Fire CAS # OTHER Immediate (acute) Check all that apply Sudden Release of Pressure Reactivity Delayed (chronic) Check all that apply Sudden Release of Pressure Reactivity Delayed (chronic) Check all that apply Sudden Release of Pressure Reactivity Delayed (chronic) Check all that apply Sudden Release of Pressure Reactivity Delayed (chronic) Check all that apply Sudden Release of Pressure Reactivity Delayed (chronic) Check all that apply Sudden Release of Pressure Reactivity Delayed (chronic) American LegalNet, Inc. www.FormsWorkflow.com Instructions 311 REPORTING Section 311 reporting is the submission of either a Material Safety Data Sheet (MSDS) or a list of reportable chemicals under Section 312 of SARA Title III (stored chemicals in quantities greater than or equal to the minimum threshold levels), grouped by hazard category. If at any time after the initial submission (i) a facility obtains a new unreported substance, (ii) a hazardous chemical present at a facility meets or exceeds its threshold level for the first time, or (iii) significant new information concerning the hazards of a chemical stored by a facility is communicated via a revised MSDS, then either an updated list or the relevant MSDS must be sent to the SERC, appropriate LEPC, and local fire department. This supplemental information is due within 90 days of receiving the new chemical or information and must be submitted to the following: • Indiana Emergency Response Commission c/o IDEM/OLQ Attn: Tier II 100 N. Senate Ave. Indianapolis, IN 46204-2251 • LEPC—County where the facility is located • Local Fire Department—County where the facility is located 1. Name of the Facility—Enter the actual name of the facility, generally the name appearing on an exterior sign at the facility. 2. 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. 3. Street Address—Provide the actual, complete street address of the facility, including number, name, and type of roadway. Providing only post office box numbers, railroads, routes, or highways is UNACCEPTABLE. 4. City—Provide the name of the city where 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 designated. 5. County—Provide the name of the county in which the facility is located. This must be consistent with the location of the city. 6. 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. 7. Email—Enter the facility’s email address. 8. Chemical Name—Provide the common name or trade name of each reportable substance or mixture stored at the facility. 9. 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. 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. 10. Provide the CAS number for the mixture or the CAS numbers for the individual chemical components of the mixture. Leave the space blank if the substance/mixture is diesel or fuel oil. Type of Chemical—Indicate if each chemical is a Section 302 EHS, has a CERCLA RQ, or is otherwise regulated. 1 American LegalNet, Inc. www.FormsWorkflow.com Physical and Health Hazards—A facility must have an MSDS for a hazardous 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 listed on the 311 reporting form. 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 Flammable Combustion Liquid Fire Pyrophoric Oxidizer Compressed Gas Sudden Release Of Pressure Explosive Organic Peroxide Unstable — R eactive Reactive Physical Health Hazards EPA HAZARD CATEGORIES Water — Reactive Highly Toxic Toxic Irritant Immediate (Acute) Sensitizer Corrosive Other adverse effects with short-term exposure Carcinogen Other adverse effects with long-term exposure 2 Health Hazards 11. Delayed (Chronic) American LegalNet, Inc. www.FormsWorkflow.com