AZSERC Tier Two Online Form

Tier Two
EMERGENCY
AND
HAZARDOUS
CHEMICAL
INVENTORY

Specific
Information
by Chemical

Facility Identification
(2a)
Name __________________________________________________________
Street _________________________________________________________
City _________________ County ____________ State ______ Zip ________

SIC CODE Dun & Bradstreet Number

FOR
OFFICIAL
USE

Owner/Operator Name
(2b)

Name _________________________Phone (_____) __________
Mail Address __________________________________________

Emergency Contact
(2c)

Name _________________________
Phone (_______)_______________
Name _________________________
Phone (_______)_______________

Title _________________
24 Hr. Phone _________
Title _______________
24 Hr. Phone ________

Important: Read all instructions before
completing form

Reporting Period (2d) From January 1 to December 31, 19_________

Check if information below is identical to the information
submitted last year.

(3)

Chemical Description

(4)

Physical
and Health
Hazards

(5)

Inventory

(6)

Storage Codes and Locations
(Non-Confidential)

Storage Locations

CAS

---

Trade Secret

Chem. Name ______________________________

Check at
that Apply
Pure
Mix
Solid
Liquid
Gas
EHS

EHS Name _________________________________

Fire

Sudden Release
of Pressure

Reactivity

Immediate (Acute

Delayed(Chronic)

Check at that apply

MAX Daily
Amount (CODE)

AVG Daily
Amount (CODE)

No. of Days
on-site (DAYS)

______________________

CAS

---

Trade Secret

Chem. Name ______________________________

Check at
that Apply
Pure
Mix
Solid
Liquid
Gas
EHS

EHS Name _________________________________

Fire

Sudden Release
of Pressure

Reactivity

Immediate (Acute

Delayed(Chronic)

Check at that apply

MAX Daily
Amount (CODE)

AVG Daily
Amount (CODE)

No. of Days
on-site (DAYS)

______________________

CAS

---

Trade Secret

Chem. Name ______________________________

Check at
that Apply
Pure
Mix
Solid
Liquid
Gas
EHS

EHS Name _________________________________

Fire

Sudden Release
of Pressure

Reactivity

Immediate (Acute

Delayed(Chronic)

Check at that apply

MAX Daily
Amount (CODE)

AVG Daily
Amount (CODE)

No. of Days
on-site (DAYS)

______________________

Certification (Read and sign after completing all sections.)(7)

I certify under penalty of law that I have personally examined and am familar with the information submitted in pages one through _________, and that based
on my inquiry of those individuals responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.

______________________________________________________________________________________________________________________________
Name and official title of owner/operator OR owner/operator's authorized representative_________________ Signature________Date Signed

I have attached a site plan

I have attached a list of site coordinate abbreviations

I have attached a description of dikes and other safeguard measures