TRI Reporting Form

2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2070-0093 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2070-0212 2070-0212 2070-0212 2070-0212 2070-0212 2070-0212 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2070-0143 2025-0010 2025-0010 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2070-0212 2070-0212 2070-0212 2070-0212 2070-0212 2070-0212 2025-0007 2025-0007 2025-0007 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2025-0009 2070-0212 2070-0212 2070-0212 2070-0212 2070-0212 2070-0212 05/1992 12/1992 12/1993 12/1994 12/1994 04/1997 04/1997 04/1997 04/1997 01/2001 01/2001 03/2003 02/2004 02/2004 08/2005 08/2006 08/2008 08/2008 10/2009 10/2009 10/2011 10/2012 10/2012 06/2014 06/2014 06/2014 06/2014 10/2018 10/2018 07/2020 02/2022 02/2022 04/2023 01/2025 01/2025 11/1994 11/1994 01/2001 01/2001 03/2003 02/2004 02/2004 08/2005 11/2006 01/2008 03/2009 10/2009 10/2009 10/2011 10/2012 10/2012 06/2014 06/2014 06/2014 06/2014 10/2018 10/2018 07/2020 02/2022 02/2022 04/2023 01/2025 01/2025 11/30/1992 11/30/1992 11/30/1992 11/30/1992 11/30/1992 04/30/2000 04/30/2000 04/30/2000 01/01/2001 01/31/2003 01/31/2003 10/31/2003 01/31/2006 01/31/2006 01/31/2008 01/31/2008 01/31/2010 03/31/2011 07/31/2011 07/31/2011 10/31/2014 10/31/2014 10/31/2014 11/30/2017 11/30/2017 11/30/2017 07/31/2018 10/31/2021 10/31/2021 03/31/2024 03/31/2024 03/31/2024 06/30/2025 12/31/2027 12/31/2027 05/31/1998 05/31/1998 01/31/1999 01/01/2001 01/31/2003 01/31/2003 10/31/2003 01/31/2006 01/31/2006 01/31/2008 01/31/2008 01/31/2010 03/31/2011 07/31/2011 07/31/2011 10/31/2014 10/31/2014 10/31/2014 11/30/2017 11/30/2017 11/30/2017 07/31/2018 10/31/2021 10/31/2021 03/31/2024 03/31/2024 03/31/2024 06/30/2025 12/31/2027 12/31/2027 04/30/2010 07/31/2011 07/31/2011 10/31/2014 10/31/2014 10/31/2014 11/30/2017 11/30/2017 11/30/2017 02/28/2018 10/31/2021 10/31/2021 03/31/2024 03/31/2024 03/31/2024 06/30/2025 12/31/2027 12/31/2027 false true

*** Do not send to EPA: This is the final copy of your form.***

Form Status:

Validation Status:

	Form Approved OMB Number: Approval Expires:
Page 1 of 6 (IMPORTANT: Read instructions before completing form; type or use fill-and-print form)

Complete form online via TRI-MEweb. For a trade secret submission, send completed forms to CGI Federal, Inc., 12601 Fair Lakes Circle, Fairfax, VA 22033. The annual public burden related to the Form R is estimated to average 35.71 hours per response for a facility filing a report on one chemical. See the Reporting Forms and Instructions for more information on submissions and the Paperwork Reduction Act.

EPA	FORM R
United States Environmental Protection Agency	Section 313 of the Emergency Planning and Community Right-to-know Act of 1986, also known as Title III of the Superfund Amendments and Reauthorization Act.

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

(includes )

WHERE TO SEND COMPLETED FORMS:	1. CGI Federal, Inc. 12601 Fair Lakes Circle Fairfax, VA 22033	2. APPROPRIATE STATE OFFICE (See instructions in Appendix F)

This section only applies if you are revising or withdrawing a previously submitted form, otherwise leave blank:

Revision (Enter up to two code(s))

[ ] [ ]

Withdrawal (Enter up to two code(s))

[ ] [ ]

Important: See Instructions to determine when "Not Applicable (NA)" boxes should be checked.

Part I. FACILITY IDENTIFICATION INFORMATION

SECTION 1. REPORTING YEAR :

SECTION 2. TRADE SECRET INFORMATION

2.1

Are you claiming the toxic chemical identified on page 2 trade secret?: [ X ] Yes (Answer question 2.2; attach substantiation forms); [ X ] NO (Do not answer 2.2; go to Section 3)

2.2

Is this copy: [ ] Sanitized [ ] Unsanitized; (Answer only if "Yes" in 2.1)

SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)

I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the submitted information is true and complete and that the amounts and values in this report are accurate based on reasonable estimates using data available to the preparers of this report.

Name and official title of owner/operator or senior management official:	Signature:	Date Signed:
	Reference Copy: Copy of Record Resides in CDX

SECTION 4. FACILITY IDENTIFICATION

4.1	Facility or Establishment Name	TRI Facility ID Number	BIA Code
	Street	Facility or Establishment Mailing Address (if different from physical street address)
	City/County/State/ZIP Code / / /	City/State/ZIP Code / /	Country (Non-US)
	City/County/Tribe/State/ZIP Code / / BIA Code: / /	City/State/ZIP Code / /	Country (Non-US)
	City/County/State/ZIP Code / / /	City/State/ZIP Code / /	Country (Non-US)

4.2

This report contains information for:
(Important: check a or b; check c or d if applicable)

a. [ X ] An Entire facility

b. [ X ] Part of a facility

c. [ X ] A Federal facility

d. [ X ] GOCO

4.3	Technical Contact name	Email Address	Telephone Number (include area code and ext.) -- -
4.4	Public Contact name	Email Address	Telephone Number (include area code and ext.) -- -
4.4	Public Contact name		Telephone Number (include area code and ext.) -- -

Page 2 of 6

4.5

SIC Code(s) (4 digits)

a. (Primary)

4.5

NAICS Code(s) (6 digits)

a. (Primary)

4.6	Dun and Bradstreet Number(s) (9 digits)
	a.
	b.

SECTION 5. PARENT COMPANY INFORMATION

5.1

Name of Parent Company Name of U.S. Parent Company (for TRI Reporting purposes)

No U.S. Parent Company (for TRI Reporting purposes) [ X ]

NA [ X ]

5.2

Parent Company's Dun & Bradstreet Number

NA [ X ]

5.3

Name of Foreign Parent Company (for TRI Reporting purposes)

No Foreign Parent Company (for TRI Reporting purposes) [ X ]

5.4

Foreign Parent Company's Dun & Bradstreet Number

NA [ X ]

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

Printed using TRI-MEweb

Page 3 of 6

*** Do not send to EPA: This is the final copy of your form.***

EPA FORM R
PART II. CHEMICAL - SPECIFIC INFORMATION

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 1. TOXIC CHEMICAL IDENTITY

(Important: DO NOT complete this section if you are reporting a mixture component in Section 2 below.)

1.1

CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.2

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.3

Generic Chemical Name (Important: Complete only if Part I, Section 2.1 is checked "Yes". Generic Name must be structurally descriptive).

1.4

Distribution of Each Member of the Dioxin and Dioxin-like Compounds Category.
(If there are any numbers in boxes 1-17, then every field must be filled in with either 0 or some number between 0.01 and 100. Distribution should be reported in percentages and the total should equal 100%. If you do not have speciation data available, indicate NA.)

NA [ X ]

NA [ ]

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1.)

2.1

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, spaces, and punctuation.)

SECTION 3. ACTIVITIES AND USES OF THE TOXIC CHEMICAL AT THE FACILITY
(Important: Check all that apply.)

3.1	Manufacture the toxic chemical:	3.2	Process the toxic chemical:	3.3	Otherwise use the toxic chemical:
a. [ X ] Produce b. [ X ] Import
If produce or import: c. [ X ] For on-site use/processing d. [ X ] For sale/distribution e. [ X ] As a byproduct f. [ X ] As an impurity		a. [ X ] As a reactant Sub-Uses: b. [ X ] As a formulation component Sub-Uses: c. [ X ] As an article component d. [ X ] Repackaging e. [ X ] As an impurity f. [ X ] Recycling		a. [ X ] As a chemical processing aid Sub-Uses: b. [ X ] As a manufacturing aid Sub-Uses: c. [ X ] Ancillary or other use Sub-Uses:

SECTION 4. MAXIMUM AMOUNT OF THE TOXIC CHEMICAL ON-SITE AT ANY TIME DURING THE CALENDAR YEAR

4.1

[

] (Enter two-digit code from instruction package.)

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE

			A. Total Release (pounds/year) (Enter range code or estimate*)	B. Basis of Estimate (Enter code)	C. Percent from Stormwater
5.1	Fugitive or non-point air emissions	NA [ X ]
5.2	Stack or point air emissions	NA [ X ]
5.3	Discharges to receiving streams or water bodies (Enter one name per box)	NA [ X ]
Stream or Water Body Name		Reach Code (optional)
5.3.1	NA
5.3.					NA %

*For Dioxin and Dioxin-like Compounds, report in grams/year
EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.	**Range Codes: A=1-10 pounds; B=11-499 pounds; C=500-999 pounds.

Page 4 of 6

*** Do not send to EPA: This is the final copy of your form.***

EPA FORM R
PART II. CHEMICAL - SPECIFIC INFORMATION (CONTINUED)

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ON-SITE (Continued)

		NA	A. Total Release (pounds/year) (Enter range code* or estimate)	B. Basis of Estimate (Enter code)
5.4-5.5	Disposal to land on-site
5.4	UIC Injections Aggregate	[ X ]
5.4.1	Class I Underground Injection wells Underground Injection onsite to Class I wells	[ X ]
5.4.2	Class II-V Underground Injection wells Underground Injection onsite to Class II-V wells	[ X ]
5.5	Disposal to land on-site
5.5.1	Total Landfill Releases	[ X ]
5.5.1.A	RCRA subtitle C landfills	[ X ]
5.5.1.B	Other landfills	[ X ]
5.5.2	Land treatment/application farming	[ X ]
5.5.3	Surface impoundment	[ X ]
5.5.3A	RCRA Subtitle C surface impoundments	[ X ]
5.5.3B	Other surface impoundments	[ X ]
5.5.4	Other disposal	[ X ]
Optional Waste Rock Piles Information You may check this box if your Section 5.5 quantities include "waste rock piles." [ X ] Enter quantity of "waste rock piles" (pounds/year*)

SECTION 6. TRANSFER(S) OF THE TOXIC CHEMICAL IN WASTES TO OFF-SITE LOCATIONS

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs)

NA [ X ]

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs)

NA [ X ]

6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs)

6.1.A Total Quantity Transferred to POTWs and Basis of Estimate

6.1.A.1 Total Transfers (pounds/year*)
(Enter range code** or estimate)

6.1.A.2 Basis of Estimate
(Enter code)

6.1. 6.1.B.
POTW Name

POTW Address

City

State

County

State

ZIP

Country
(Non-US)

A. Quantity Transferred to this POTW
(pounds/year*) (Enter range code**or estimate)

B. Basis of Estimate
(Enter code)

C. Type of Waste Treatment/Disposal
(Enter code)

. NA

*For Dioxin and Dioxin-like Compounds, report in grams/year
EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.	**Range Codes: A=1-10 pounds; B=11-499 pounds; C=500-999 pounds.

Page 5 of 6

*** Do not send to EPA: This is the final copy of your form.***

EPA FORM R
PART II. CHEMICAL - SPECIFIC INFORMATION (CONTINUED)

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS	NA [ X ]
SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS

6.2. Off-Site EPA Identification Number (RCRA ID No.)
Off-Site Location Name:
Off-Site Address:

City

State

County

State

ZIP

Country
(Non-US)

Is location under control of reporting facility or parent company?

[ X ] Yes [ X ] No

A. Total Transfer (pounds/year) (Enter range code* or estimate)	B. Basis of Estimate (Enter code)	C. Type of Waste Treatment/Disposal/ Recycling/Energy Recovery (Enter code)
.	.	.

SECTION 7A. ONSITE WASTE TREATMENT METHODS AND EFFICIENCY
[ X ] Not Applicable (NA) - Check here if no on-site waste treatment is applied to any waste stream containing the toxic chemical or chemical category.
a. General Waste Stream (enter code)	b. Waste Treatment Method(s) Sequence [enter 3-character code(s)]	c. Influent Concentration	d. % Waste Treatment Efficiency	e. Based on Operating Data?
7A. a	7A. b	7A. c	7A. d	7A. e
	:			X

SECTION 7A. ONSITE WASTE TREATMENT METHODS AND EFFICIENCY
[ X ] Not Applicable (NA) - Check here if no on-site waste treatment is applied to any waste stream containing the toxic chemical or chemical category.
a. General Waste Stream (enter code)	b. Waste Treatment Method(s) Sequence [enter 3-character code(s)]	c. Waste Treatment Efficiency Estimate
7A. a	7A. b	7A. c
	:

*For Dioxin and Dioxin-like Compounds, report in grams/year
EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.	**Range Codes: A=1-10 pounds; B=11-499 pounds; C=500-999 pounds.

Page 6 of 6

*** Do not send to EPA: This is the final copy of your form.***

EPA FORM R
PART II. CHEMICAL - SPECIFIC INFORMATION (CONTINUED)

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

SECTION 7B. ON-SITE ENERGY RECOVERY PROCESSES
[ X ] NA - Check here if no on-site energy recovery is applied to any waste stream containing the toxic chemical or chemical category.
Energy Recovery Methods [Enter 3-character code(s)]
.

SECTION 7C. ON-SITE RECYCLING PROCESSES
[ X ] NA - Check here if no on-site recycling is applied to any waste stream containing the toxic chemical or chemical category.
Recycling Methods [Enter 3-character code(s)]
.

SECTION 8. SOURCE REDUCTION AND WASTE MANAGEMENT
		Column A Prior Year (pounds/year*)	Column B Current Reporting Year (pounds/year*)	Column C Following Year (pounds/year*)	Column D Second Following Year (pounds/year*)
8.1	Quantity Released	NA	NA	NA	NA
8.1		8.1 - 8.7 Production-Related Waste Managed
8.1a	Total on-site disposal to Class I Underground Injection Wells, RCRA Subtitle C landfills, and other landfills	NA	NA	NA	NA
8.1b	Total other on-site disposal or other releases	NA	NA	NA	NA
8.1c	Total off-site disposal to Class I Underground Injection Wells, RCRA Subtitle C landfills, and other landfills	NA	NA	NA	NA
8.1d	Total other off-site disposal or other releases	NA	NA	NA	NA
8.2	Quantity used for energy recovery on-site	NA	NA	NA	NA
8.3	Quantity used for energy recovery off-site	NA	NA	NA	NA
8.4	Quantity recycled on-site	NA	NA	NA	NA
8.5	Quantity recycled off-site	NA	NA	NA	NA
8.6	Quantity treated on-site	NA	NA	NA	NA
8.7	Quantity treated off-site	NA	NA	NA	NA
8.8	Quantity released to the environment as a result of remedial actions, catastrophic events, or one-time events not associated with production processes (pounds/year) Non-production-related waste managed total**		NA
8.8a	Non-production-related on-site air total
8.8b	Non-production-related on-site water total
8.8c	Non-production-related on-site land total
8.8d	Non-production-related off-site total
8.9	[X] [ ] Production ratio or [X] [ ] Activity ratio (select one and enter value to right)		Production ratio or activity index		NA
8.10	Did your facility engage in any source reduction activities for this chemical during the reporting year? If not, enter "NA" in Section 8.10.1 and answer Section 8.11.					Did your facility engage in any newly implemented source reduction activities for this chemical during the reporting year? If so, complete the following section; if not, check NA.	NA [X]

	Source Reduction Activities (Enter code(s))	Methods to Identify Activity (Enter code(s))		Estimated annual reduction (Enter code(s)) (optional)
8.10.1	NA
8.10.
8.11	If you wish to submit additional optional information on source reduction, recycling, or pollution control activities, check "Yes."		Yes [ X ]

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

*For Dioxin and Dioxin-like Compounds, report in grams/year
** Includes quantities released to the environment or transferred off-site as a result of remedial actions, catastrophic events, or other one-time events not associated with production processes

TRI Facility ID Number

Toxic Chemical, Category, or Generic Name

Additional optional information on source reduction, recycling, or pollution control activities.

Section 8.11: If you wish to submit additional optional information on source reduction, recycling, or pollution control activities, provide it here.
Topic	Comment

Section 9.1: If you wish to submit any miscellaneous, additional, or optional information regarding your Form R submission, provide it here.
Topic	Comment

Miscellaneous, additional, or optional information regarding the Form R submission

*** Do not send to EPA: This is the final copy of your form.***

Page 2 of 4

Form Approved OMB Number:

Approval Expires:

EPA	FORM R Schedule 1	TRI Facility ID Number:
United States Environmental Protection Agency	PART II. CHEMICAL-SPECIFIC INFORMATION (continued)

Section 5. Quantity Of Dioxin And Dioxin-Like Compounds Entering Each Environmental Medium On-site (continued)

5.4 Underground Injection

5.5 Disposal to Land On-site

5.4.1

5.4.2

5.5.1A

5.5.1B

5.5.2

5.5.3A

5.5.3B

5.5.4

Underground Injection on-site to Class I Wells Class I Underground Injection Wells

Underground Injection on-site to Class II-V Wells Class II-V Underground Injection Wells

RCRA Subtitle C landfills

Other landfills

Land treatment/application farming

RCRA Subtitle C surface impoundment

Other surface impoundment

Other disposal

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

Printed using TRI-MEweb

*** Do not send to EPA: This is the final copy of your form.***

Page 3 of 4

Form Approved OMB Number:

Approval Expires:

EPA	FORM R Schedule 1	TRI Facility ID Number:
United States Environmental Protection Agency	PART II. CHEMICAL-SPECIFIC INFORMATION (continued)

SECTION 6. TRANSFERS OF DIOXIN AND DIOXIN-LIKE COMPOUNDS IN WASTES TO OFF-SITE LOCATIONS

6.1 DISCHARGES TO PUBLICLY-OWNED TREATMENT WORKS (POTWs)

NA [ X ]

6.1.A.3 Mass (grams) of each compound in the category (1-17)

6.1.

C. Mass (grams) of each compound in the category (1-17)

6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS

NA [ X ]

6.2.

D. Mass (grams) of each compound in the category (1-17)

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

Printed using TRI-MEweb

*** Do not send to EPA: This is the final copy of your form.***

Page 4 of 4

Form Approved OMB Number:

Approval Expires:

EPA	FORM R Schedule 1	TRI Facility ID Number:
United States Environmental Protection Agency	PART II. CHEMICAL-SPECIFIC INFORMATION (continued)

SECTION 8. SOURCE REDUCTION AND WASTE MANAGEMENT FOR DIOXIN AND DIOXIN-LIKE COMPOUNDS (current year only)

8.1a

8.1b

8.1c

8.1d

8.2

8.3

8.4

8.5

8.6

8.7

8.8

Total on-site disposal to Class 1 Underground Injection Wells, RCRA Subtitle C landfills, and other landfills

Total other on-site disposal or other releases

Total off-site disposal to Class 1 Underground Injection Wells, RCRA Subtitle C landfills, and other landfills

Total other off-site disposal or other releases

Quantity used for energy recovery on-site

Quantity used for energy recovery off-site

Quantity recycled on-site

Quantity recycled off-site

Quantity treated on-site

Quantity treated off-site

Quantity released to the environment as a result of remedial actions, catastrophic events, or one-time events not associated with production processes

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

Printed using TRI-MEweb

*** File Copy Only: Do Not Submit Paper Form to EPA ***

Form Status:

Validation Status:

	Form Approved OMB Number: Approval Expires:
(IMPORTANT: Read instructions before completing form; type or use fill-and-print form)

United States
Environmental Protection Agency

TOXICS CHEMICAL RELEASE INVENTORY
FORM A

TRI Facility ID Number

Complete form online via TRI-MEweb. For a trade secret submission, send completed forms to CGI Federal, Inc., 12601 Fair Lakes Circle, Fairfax, VA 22033. The annual public burden related to the Form A is estimated to average 21.96 hours per response for a facility filing a report on one chemical. See the Reporting Forms and Instructions for more information on submissions and the Paperwork Reduction Act.

WHERE TO SEND COMPLETED FORMS:	1. CGI Federal, Inc. 12601 Fair Lakes Circle Fairfax, VA 22033 * File Copy Only: Do Not Submit Paper Form to EPA *	2. APPROPRIATE STATE OFFICE (See instructions in Appendix F)

This section only applies if you are revising or withdrawing a previously submitted form, otherwise leave blank:

Revision (Enter up to two code(s))

[ ] [ ]

Withdrawal (Enter up to two code(s))

[ ] [ ]

Important: See Instructions to determine when "Not Applicable (NA)" boxes should be checked.

Part I. FACILITY IDENTIFICATION INFORMATION

SECTION 1. REPORTING YEAR :

SECTION 2. TRADE SECRET INFORMATION

2.1

Are you claiming the toxic chemical identified on page 2 trade secret?: [ X ] Yes (Answer question 2.2; attach substantiation forms); [ X ] NO (Do not answer 2.2; go to Section 3)

2.2

Is this copy: [ ] Sanitized [ ] Unsanitized; (Answer only if "Yes" in 2.1)

SECTION 3. CERTIFICATION (Important: Read and sign after completing all form sections.)

Pursuant to 40 CFR 372.27(a)(1), "I hereby certify that to the best of my knowledge and belief for the toxic chemical(s) listed in this statement, for this reporting year, the annual reportable amount for each chemical, as defined in 40 CFR 372.27(a)(1), did not exceed 5,000 pounds, which included no more than 2,000 pounds of total disposal or other releases to the environment, and that the chemical was manufactured, or processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year;" and/or Pursuant to 40 CFR 372.27(a)(2), "I hereby certify that to the best of my knowledge and belief for the toxic chemical(s) of special concern listed in this statement, there were zero disposals or other releases to the environment (including disposals or other releases that resulted from catastrophic events) for this reporting year, the "Annual Reportable Amount of a Chemical of Special Concern" for each such chemical, as defined in 40 CFR 372.27(a)(2), did not exceed 500 pounds for this reporting year, and that the chemical was manufactured, or processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year." Pursuant to 40 CFR 372.27(a)(1), "I hereby certify that to the best of my knowledge and belief for the toxic chemical(s) listed in this statement, for this reporting year, the annual reportable amount for each chemical, as defined in 40 CFR 372.27(a)(1), did not exceed 5,000 pounds, which included no more than 2,000 pounds of total disposal or other releases to the environment, and that the chemical was manufactured, or processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year;" and/or Pursuant to 40 CFR 372.27(a)(2), "I hereby certify that to the best of my knowledge and belief for the toxic chemical(s) of special concern listed in this statement, there were zero disposals or other releases to the environment (including disposals or other releases that resulted from catastrophic events) for this reporting year, the "Annual Reportable Amount of a Chemical of Special Concern" for each such chemical, as defined in 40 CFR 372.27(a)(2), did not exceed 500 pounds for this reporting year, and that the chemical was manufactured, or processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year." I hereby certify that to the best of my knowledge and belief, for each toxic chemical listed in the statement, the annual reportable amount as defined in 40 CFR 372.27 (a), did not exceed 500 pounds for this reporting year and the chemical was manufactured, processed, or otherwise used in an amount not exceeding 1 million pounds during this reporting year.

Name and official title of owner/operator or senior management official:	Signature:	Date Signed:
	Reference Copy: Copy of Record Resides in CDX

SECTION 4. FACILITY IDENTIFICATION

4.1

Facility or Establishment Name

TRI Facility ID Number

BIA Code

Street

Facility or Establishment Mailing Address (if different from physical street address)

City/County/State/ZIP Code
/ / /

City/State/ZIP Code
/ /

Country (Non-US)
/

City/County/Tribe/State/ZIP Code
/ / BIA Code: / /

City/State/ZIP Code
/ /

Country (Non-US)
/

City/County/State/ZIP Code
/ / /

City/State/ZIP Code
/ /

Country (Non-US)
/

4.2

This report contains information for: (Important: check c or d if applicable)

c. [ X ] A Federal facility

d. [ X ] GOCO

4.3

Technical Contact name

Email Address

Telephone Number (include area code and ext.)
-- -

4.4

Public Contact name

Email Address

Telephone Number (include area code and ext.)
-- -

4.4

Intentionally left blank

4.5

SIC Code(s) (4 digits)

a. (Primary)

4.5

NAICS Code(s) (6 digits)

a. (Primary)

4.6	Dun and Bradstreet Number(s) (9 digits)
	a.
	b.

SECTION 5. PARENT COMPANY INFORMATION

5.1

Name of Parent Company Name of U.S. Parent Company (for TRI Reporting purposes)

No U.S. Parent Company (for TRI Reporting purposes) [ X ]

NA [ X ]

5.2

Parent Company's Dun & Bradstreet Number

NA [ X ]

5.3

Name of Foreign Parent Company Name of Foreign Parent Company (for TRI Reporting purposes)

No Foreign Parent Company (for TRI Reporting purposes) [ X ]

NA [ X ]

5.4

Foreign Parent Company's Dun & Bradstreet Number

NA [ X ]

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

Printed using TRI-MEweb

4 IMPORTANT: Read instructions before completing form; type or use fill-and-print form

EPA FORM A
PART II. CHEMICAL IDENTIFICATION

Do not use this form for reporting PBT chemicals including Dioxin and Dioxin-like Compounds* Do not use this form for reporting Dioxin and Dioxin-like Compounds*

TRI Facility ID Number

SECTION 1. TOXIC CHEMICAL IDENTITY

Report of

1.1

CAS Number (Important: Enter only one number as it appears on the Section 313 list. Enter category code if reporting a chemical category.)

1.2

Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)

1.3

Generic Chemical Name (Important: Complete only if Part I, Section 2.1 is checked "Yes". Generic Name must be structurally descriptive).

SECTION 2. MIXTURE COMPONENT IDENTITY (Important: DO NOT complete this section if you completed Section 1.)

2.1

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, spaces, and punctuation.)

Section 9.2: If you wish to submit any miscellaneous, additional, or optional information regarding your Form A submission, provide it here.
Topic	Comment

See the TRI Reporting Forms and Instructions Manual for the list of PBT Chemicals(including Dioxin and Dioxin-like Compounds) See the TRI Reporting Forms and Instructions Manual for the TRI-listed Dioxin and Dioxin-like Compounds
EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

*** Do not send to EPA: This is the final copy of your form.***

Page 1 of 4

Form Approved OMB Number:

Approval Expires:

EPA	FORM R Schedule 1	TRI Facility ID Number:
United States Environmental Protection Agency	PART II. CHEMICAL-SPECIFIC INFORMATION (continued)

Section 5. Quantity Of Dioxin And Dioxin-Like Compounds Entering Each Environmental Medium On-site

5.1

5.2

5.3 Discharges to receiving streams or water bodies NA [ X ]

Fugitive or non-point air emissions

Stack or point air emissions

5.3.

If additional pages of Section 6.1 or 6.2 are attached, indicate the total number of pages in this box
and indicate the Section 6.1 or 6.2 page number in this box (Example: 1,2,3, etc.)

EPA Form 9350-2 (Rev. ) - Previous editions are obsolete.

Printed using TRI-MEweb

D. Mass
(grams)
of
each
compound
in
the
category
(1-17)

C. Mass
(grams)
of
each
compound
in
the
category
(1-17)

1 6.2_ . Mass (grams) of each compound in the Category (1-17)

1 . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1

F. Mass
(grams)
of
each
compound
in
the
category
(1-17)

0 0 0