Nonconfidential Location Information {52015}

NONCONFIDENTIAL LOCATION INFORMATION State Form 52015 (5-05) Indiana Department of Environmental Management Indiana Emergency Response Commission Read Instruction found after this form before completing this form. Page Reporting Period: From January 1 to December 31, _____ Check if information below is identical to the information submitted last year of Important: Read all instructions before completing form. Tier II EMERGENCY AND HAZARDOUS CHEMICAL INVENTORY Specific Information by Chemical Facility Identification Facility ID # _______________________________ (From Mailing Label) Owner/Operator Name (Mailing Address) Name _____________________________________________________ Phone ( ) ___________________________ Name _________________________________________________________ Street Address ___________________________________________ City __________________________________ County ___________________________________ ZIP _________ E-mail ________________________________ SIC Code: ________________________________ Dunn & Bradstreet: __________________________________ Mailing Address ____________________________________________________________________________________ Emergency Contact Name ______________________________________________________ Title _________________________________ Phone ( ) ___________________________________ 24-Hr. Phone ( ) _______________________________ Name _______________________________________________________ Title _________________________________ Phone ( ) ___________________________________ 24-Hr. Phone ( ) _______________________________ OFFICIAL USE ONLY (DO NOT FILL) Date Received _____________________________ Container Type Health Hazards CAS__________________________________ Chem. Name__________________________ Check all that Apply: Trade Secret Fire Sudden Release of pressure ______ Max. Daily Amount (Code) ______ Avg. Daily Amount (Code) ______ No. of Days On-site (Days) Reactivity Pure Mix Solid Liquid Gas EHS Immediate (acute) Delayed (chronic) Fire Trade Secret Sudden Release of pressure EHS Name __________________________________ CAS ________________________________ Chem. Name _________________________ Check all that apply: Pure Mix Solid Liquid Gas EHS ______ Max. Daily Amount (Code) ______ Avg. Daily Amount (Code) ______ No. of Days On-site (Days) Reactivity Immediate (acute) Delayed (chronic) EHS Name ___________________________________ Pressure Chemical Description Inventory 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. _____________________________________________________________________________ Name and official title of owner/operator OR authorized representative __________________________________________ Signature __________________ Date signed I have attached a site plan I have attached a list of the site coordinate abbreviations I have attached a description of dikes and other safeguards American LegalNet, Inc. www.FormsWorkflow.com Optional Physical and Temperature Storage Codes and Locations (Nonconfidential) Storage Location CONFIDENTIAL LOCATION INFORMATION State Form 52015 (5-05) Indiana Department of Environmental Management Indiana Emergency Response Commission Read Instruction found after this form before completing this form. Page Reporting Period: From January 1 to December 31, ____ Check if information below is identical to the information submitted last year of Important: Read all instructions before completing form. Tier II EMERGENCY AND HAZARDOUS CHEMICAL INVENTORY Specific Information by Chemical Facility Identification Facility ID # _______________________________ (From Mailing Label) Owner/Operator Name (Mailing Address) Name _____________________________________________________ Phone ( ) __________________________ Name _________________________________________________________ Street Address ___________________________________________ City __________________________________ Mailing Address ___________________________________________________________________________________ Emergency Contact Phone ( ) ___________________________________ 24-Hr. Phone ( ) _______________________________ Name _______________________________________________________ Title ________________________________ Phone ( ) ___________________________________ Temperature 24-Hr. Phone ( ) _______________________________ County ___________________________________ ZIP _________ E-mail ________________________________ Name ______________________________________________________ Title ________________________________ SIC Code: ________________________________ Dunn & Bradstreet: __________________________________ OFFICIAL USE ONLY (DO NOT FILL) Date Received _____________________________ Chemical Description 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 Optional Container Type Pressure Storage Codes and Locations (Confidential) Storage Location 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