DIVISION OF LABOR
IOWA EMERGENCY RESPONSE COMMISSION
1000 EAST GRAND AVENUE
DES MOINES, IOWA 50319-0209
IMPORTANT
TIER TWO
EMERGENCY AND HAZARDOUS
CHEMICAL INVENTORY FORM
ENCLOSED
(DO NOT DISCARD)
* If you do electronic submission disregard this
form.
PLEASE READ
IMPORTANT INFORMATION
Tier Two Facility Coordinator:
Enclosed is the 2002 Reporting Year Tier Two form. The Form is due March 1 of 2003. Do not
submit form until AFTER January 1, 2003 - (this helps our electronic processing). Please
note some changes to the form.
On the reverse side of the Tier Two form you will find a peel off mailing label. Please affix the
label to the designated area on the Tier Two form. Please correct any errors that occur on the
label.
We also provide a box to check if all the chemical information is identical to all the chemical
information submitted last year. If all the chemical information remains the same you still
need to fill out the form.
The US EPA is providing computer software which allows facilities to prepare Tier Two forms on a
Personal Computer (PC) or 100% IBM compatible computer. The Tier Two software is available
free of charge. Facilities should download the software from US EPA's website at www.epa.gov/
ceppo/tier2.htm.
Facilities choosing to use the computer software should submit a magnetic disk of the The Tier
Two information and the magnetic submission certification statement, supplied for you with your
computer software. We do not need a print out of the Tier Two Form, when you send a magnetic
submission certification statement.
Additional Tier Two information for Iowa may be found at www.iowaworkforce.org/labor/serc.htm.
The Iowa Emergency Response Commission will only accept the Iowa computer generated,
federal or Iowa Tier Two forms. All incomplete or other forms will be returned. If you have any
questions, please contact Ellen Hester at (515) 281-6175.
Your Tier II report will be returned to you if you do not include the following:
North American Industrial Classification System (NAICS)
(To obtain your facility's NAICS, please use the internet site at
www.osha.gov/oshstats/sicser.html or call (515) 281-8178.)
Emergency Contact Information
TIER TWO INSTRUCTIONS
GENERAL INFORMATION
Submission of this Tier Two form (when requested) is required by Title
If you submit Tier One rather than Tier Two, you may still be required
III of the Superfund Amendments and Reauthorization Act of 1986.
to submit Tier Two information upon request.
Section 312. Public Law 99-499. codified at 42 U.S.C. Section 11022.
The purpose of this Tier Two form is to provide State and local officials
WHAT CHEMICALS ARE EXCLUDED
and the public with specific information on hazardous chemicals
Section 311(e) of Title III excludes the following substances:
present at your facility during the past year.
(I) Any food, food additive, color additive, drug, or cosmetic regulated
by the Food and Drug Administration;
CERTIFICATION
(II) Any substance present as a solid in any manufactured item to the
The owner or operator or the officially designated representative of the
extent exposure to the substance does not occur under normal
owner or operator must certify that all information included in the Tier
conditions of use;
Two submission is true, accurate, and complete. On the first page of
(III) Any substance to the extent it is used for personal, family, or
the Tier Two report, enter your full name and official title. Sign your
household purposes, or is present in the same form and concentration
name and enter the current date. Also, enter the total number of pages
as a product packaged for distribution and use by the general public;
included in the Confidential and Non-Confidential information Sheets
(IV) Any substance to the extent it is used in a research laboratory or a
as well as all attachments. An original signature is required on at least
hospital or other medical facility under the direct supervision of a
the first page of the submission. Submissions to the SERC, LEPC, and
technically qualified individual;
fire department must each contain an original signature on at least the
(V) Any substance to the extent it is used in routine agricultural
first page. Subsequent pages must contain either an original signature,
operations or is a fertilizer held for sale by a retailer to the ultimate
a photocopy of the original signature, or a signature stamp. Each page
customer.
must contain the date on which the original signature was affixed to the
first page of the submission and the total number of pages in the
OSHA regulations, Section 1910.1200(b), stipulate exemptions from
submission.
the requirement to prepare or have available an MSDS.
YOU MUST PROVIDE ALL INFORMATION REQUESTED ON THIS
REPORTING THRESHOLDS
FORM TO FULFILL TIER TWO REPORTING REQUIREMENTS.
Minimum thresholds have been established for Tier One/Tier Two
reporting under Title III, Section 312. These thresholds are as follows:
This form may be submitted in place of the Tier One form.
For Extremely Hazardous Substances (EHSs) designated under
WHO MUST SUBMIT THIS FORM
section 302 of Title III, the reporting threshold is 500 pounds (or 227
Section 312 of Title III requires that the owner or operator of a facility
kg.) or the threshold planning quantity (TPQ), whichever is lower:
submit this Tier Two form if so requested by a State emergency
response commission, a local emergency planning committee, or a fire
For retail gasoline stations the reporting threshold is 75,000
department with jurisdiction over the facility.
gallons for gasoline and 100,000 gallons for diesel.
This request may apply to the owner or operator of any facility that is
For all other hazardous chemicals for which facilities are required to
required, under regulations implementing the Occupational Safety and
have or prepare an MSDS, the minimum reporting threshold is 10,000
Health Act of 1970, to prepare or have available a Material Safety Data
pounds (or 4.540 kg.).
Sheet (MSDS) for a hazardous chemical present at the facility. MSDS
requirements are specified in the Occupational Safety and Health
You need to report hazardous chemicals that were present at your
Administration (OSHA) Hazard Communication Standard, found in Title
facility at any time during the previous calendar year at levels that
29 of the Code of Federal Regulations at 搂 1910.1200.
equal or exceed these thresholds. For instructions on threshold
Iowa Administrative Codes (IAC) 605-104.1(1) and 605-104.3(2)
determinations for components of mixtures, see 鈥淲hat About Mix颅
require facilities to use a Tier Two form to comply with both
tures?鈥? on page 2 of these instructions.
sections 302 and 312 of Title III.
This form does not have to be submitted if all of the chemicals located
A requesting official may limit the responses required under Tier Two
at your facility are excluded under Section 311(e) of Title III.
by specifying particular chemicals or groups of chemicals. Such
requests apply to hazardous chemicals regardless of established
WHAT CHEMICALS ARE INCLUDED
thresholds.
You must report the required information on this Tier Two form for each
hazardous chemical present at your facility in quantities equal to or
INSTRUCTIONS
greater than established threshold amounts (discussed below), unless
Please read these instructions carefully, Print or type all responses.
the chemicals are excluded under Section 311(e) of Title III. Hazardous
chemicals are any substance for which your facility must maintain an
WHEN TO SUBMIT THIS FORM
MSDS under OSHA鈥檚 Hazard Communication Standard.
Owners or operators of facilities that have hazardous chemicals on
Facilities in Iowa that are subject to the requirements of Section 302 of
hand in quantities equal to or greater than set threshold levels must
Title III shall use a Tier Two form to report covered extremely hazard颅
submit Tier Two forms by March 1.
ous substances.
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If you choose to submit Tier One, rather than Tier Two, be aware that
IDENTICAL INFORMATION
you may have to submit Tier Two information later, upon request of an
Check the individual box in each chemical area, if the chemical
authorized official. You must submit the Tier Two form within 30 days
information submitted is the same information submitted last year.
of receipt of a written request.
Chemical descriptions, hazards, amounts, and locations must be
provided in this year鈥檚 form, even if the information is identical to that
WHERE TO SUBMIT THIS FORM
submitted last year.
Send either a completed Tier One form or Tier Two form(s) to each of
the following organizations:
CHEMICAL INFORMATION:
1. Your State Emergency Response Commission. (Address on
Description, Hazards, Amounts, and Locations
Cover)
2. Your Local Emergency Planning Committee. The main section of the Tier Two form requires specific information on
3. The fire department with jurisdiction over your facility. amounts and locations of hazardous chemicals, as defined in the
OSHA Hazard Communication Standard.
If a Tier Two form is submitted in response to a request, send the
completed form to the requesting agency. If you choose to indicate that all of the information on a specific
hazardous chemical is identical to that submitted last year, check the
PENALTIES appropriate individual box provided in each individual chemical area.
Any owner or operator who violates any Tier Two reporting require颅 Chemical descriptions, hazards, amounts, and locations must be
ments shall be liable to the United States for a civil penalty of up to provided even if the information is identical to that submitted last year.
$25,000 for each such violation. Each day a violation continues shall
constitute a separate violation. 鈥hat units should I use?
If your Tier Two responses require more than one page, use additional Calculate all amounts as weight in pounds. To convert gas or liquid
forms and fill in the page number at the top of the form. volume to weight in pounds, multiply by an appropriate density factor.
REPORTING PERIOD 鈥? What about mixtures?
Enter the appropriate calendar year, beginning January 1 and ending
December 31. If a chemical is part of a mixture, you have the option of reporting
either the weight of the entire mixture or only the portion of the
FACILITY IDENTIFICATION mixture that is a particular hazardous chemical (e.g., if a hazardous
Enter the full name of your facility (and company identifier where solution weighs 100 lbs. but is composed of only 5% of a particular
appropriate). hazardous chemical, you can indicate either 100 lbs. of the mixture or 5
lbs. of the chemical).
Enter the full street address or state road, if a street address is not
available, enter other appropriate identifiers that describe the physical The option used for each mixture must be consistent with the option
location of your facility (e.g., longitude and latitude). Include city, used in your Section 311 reporting.
county, state, and zip code.
Because EHSs are important to Section 303 planning, EHSs have
Enter the primary Standard Industrial Classification (SIC) code and the lower thresholds. The amount of an EHS at a facility (both pure EHS
Dun & Bradstreet number for your facility. The financial officer of your substances and EHSs in mixtures) must be aggregated for purposes
facility should be able to provide the Dun & Bradstreet number. If your of threshold determination. It is suggested that the aggregation calcu
firm does not have this information, contact the State or regional office lation be done as a first step in making the threshold determination.
of Dun & Bradstreet to obtain your facility number or have one Once you determine whether a threshold for an EHS has been
assigned. reached, you should report either the total weight of the EHS at your
facility, or the weight of each mixture containing the EHS.
OWNER/OPERATOR
Enter the owner鈥檚 or operator鈥檚 full name, mailing address, and phone
number.
EMERGENCY CONTACT (MUST BE INCLUDED)
Enter the name, title, and work phone number of at least one local
person or office who can act as a referral if emergency responders
need assistance in responding to a chemical accident at the facility.
Provide an emergency phone number where such emergency
information will be available 24 hours a day, every day. This require颅
ment is mandatory. The facility must make some arrangement to
ensure that a 24 hour contact is available.
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CHEMICAL DESCRIPTION
MAXIMUM AMOUNT
1. Enter the Chemical Abstract Service registry number (CAS). For
1. For each hazardous chemical, estimate the greatest amount present
mixtures, enter the CAS number of the mixture as a whole if it has
at your facility on any single day during the reporting period.
been assigned a number distinct from its constituents. For a mixture
2. Find the appropriate range value code in Table I.
that has no CAS number, leave this item blank or report the CAS
numbers of as many constituent chemicals as possible.
3. Enter this range value as the Maximum Amount..
If you are withholding the name of a chemical in accordance with
TABLE I REPORTING RANGES
criteria specified in Title III, Section 322, enter the generic class or
Range Weight Range in Pounds
category that is structurally descriptive of the chemical (e.g., list
Value From . . . . To . . . .
toulene diisocyanate as organic isocyanate) and check the box
01 0 99
marked Trade Secret. Trade secret information should be submitted
02 100 999
to EPA and must include a substantiation. Please refer to EPA鈥檚 final
03 1,000 9,999
regulation on trade secrecy (53 FR 28772, July 29, 1988) for
04 10,000 99,999
detailed information on how to submit trade secrecy claims.
05 100,000 999,999
06 1,000,000 9,999,999
2. Enter the chemical name or common name of each hazardous
07 10,000,000 49,999,999
chemical.
08 50,000,000 99,999,999
09 100,000,000 499,999,999
3. Check box for all applicable descriptors: pure or mixture: and solid,
10 500,000,000 999,999,999
liquid, or gas; and whether the chemical is or contains an EHS.
11 1 billion higher than 1 billion
4. If the chemical is a mixture containing an EHS, enter the chemical
If you are using this form as a worksheet for completing Tier One, enter
name of each EHS in the mixture.
the actual weight in pounds in the shaded space below the response
blocks. Do this for both Maximum Amount and Average Daily Amount.
EXAMPLE:
You have pure chlorine gas on hand, as well as two mixtures that
EXAMPLE:
contain liquid chlorine. You write 鈥渃hlorine鈥? and enter the CAS number.
Then you check 鈥減ure鈥? and 鈥渕ix鈥? 鈥? as well as 鈥渓iquid鈥? and 鈥済as鈥?.
You received one large shipment of a solvent mixture last year. The
shipment filled five 5,000 gallon storage tanks. You know that the
PHYSICAL AND HEALTH HAZARDS
solvent contains 10% benzene, which is a hazardous chemical.
For each chemical you have listed, check all the physical and health
hazard boxes that apply. These hazard categories are defined in 40
You figure that 10% of 25,000 gallons is 2,500 gallons. You also know
CFR 370.2. The two health hazard categories and three physical
that the density of benzene is 7.29 pounds per gallon, so you multiply
hazard categories are a consolidation of the 23 hazard categories
2,500 gallons by 7.29 pounds per gallon to get a weight of 18,225
defined in the OSHA Hazard Communication Standard, 29 CFR
pounds.
1910.1200.
Then you look at Table I and find that the range value 04 corresponds
Hazard Category Comparison For Reporting
to 18,225. You enter 04 as the Maximum Amount.
Under Sections 311 and 312
EPA鈥檚 OSH鈥檚
(If you are using the form as a worksheet for completing a Tier One
Hazard Categories Hazard Categories
form, you should write 18,255 in the shaded area.)
Fire Hazard Flammable
Combustion Liquid
Pyrophoric
Oxidizer
Sudden Release Explosive
of Pressure Compressed Gas
Reactive Unstable Reactive
Organic Peroxide
Water Reactive
Immediate (Acute) Highly Toxic Other hazardous
Health Hazards Toxic Chemicals with an
Irritant adverse effect with
Sensitizer short term exposure
Corrosive
Delayed (Chronic) Carcinogens
Health Hazard
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AVERAGE DAILY AMOUNT
Table II - STORAGE TYPES
1. For each hazardous chemical, estimate the average weight in
CODES Types of Storage
pounds that was present at your facility during the year.
A Above ground tank
To do this, total all daily weights and divide by the number of days
B Below ground tank
the chemical was present on the site.
C Tank inside building
D Steel drum
2. Find the appropriate range value in Table I.
E Plastic or non-metallic drum
F Can
3. Enter this range value as the Average Daily Amount.
G Carboy
H Silo
I Fiber drum
EXAMPLE:
J Bag
K Box
The 25,000-gallon shipment of solvent you received last year
L Cylinder
was gradually used up and completely gone in 315 days. The
M Glass bottles or jugs
sum of the daily volume levels in the tank is 4,536,000 gallons.
N Plastic bottles or jugs
By dividing 4, 536,000 gallons by 315 days on-site, you
O Tote bin
calculate an average daily amount of 14,400 gallons.
P Tank wagon
Q Rail car
You already know that the solvent contains 10% benzene,
R Other
which is a hazardous chemical. Since 10% of 14,400 is 1,440,
you figure that you had an average of 1,440 gallons of benzene.
Table III - TEMPERATURE
You also know that the density of benzene is 7.29 pounds per
AND PRESSURE CONDITIONS
gallon, so you multiply 1,440 by 7.29 to get a weight of 10,500
CODES Storage Conditions
pounds.
(PRESSURE)
1 Ambient pressure
Then you look at Table I and find that the range value 04
2 Greater than ambient pressure
corresponds to 10,500. You enter 04 as the Average Daily
3 Less than ambient pressure
Amount.
(TEMPERATURE)
(If you are using the form as a worksheet for completing a
4 Ambient temperature
Tier One form, you should write 10,500 in the shaded area.)
5 Greater than ambient temperature
6 Less than ambient temperature
NUMBER OF DAYS ON-SITE
but not cryogenic
Enter the number of days that the hazardous chemical was found on-
7 Cryogenic conditions
site.
EXAMPLE:
EXAMPLE:
The benzene in the main building is kept in a tank inside the
The solvent composed of 10% benzene was present for
building, at ambient pressure and less than ambient temperature.
315 days at your facility. Enter 315 in the space provided.
Table II shows you that the code for a tank inside a building is C.
Table III shows you that the code for ambient pressures is 1,
STORAGE CODES AND STORAGE LOCATIONS and the code for less than ambient temperature is 6.
List all non-confidential chemical locations in this column, along with
storage types/conditions associated with each location. Please note
CONTAINER TYPE
that a particular chemical may be located in several places around the
TEMPERATURE
facility. Each row of boxes followed by a line represents a unique
PRESSURE
SAMPLE
location for the same chemical.
C 1 6
Storage Codes: indicate the types and conditions of storage present:
a. Look at Table II. For each location, find the appropriate storage type
and enter the corresponding code in the first box.
b. Look at Table III. For each location, find the appropriate storage
types for pressure and temperature conditions. Enter the applicable
pressure code in the second box. Enter the applicable temperature
code in the third box.
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Storage Locations:
Provide a brief description of the precise location of the chemical, so
that emergency responders can locate the area easily. You may find it
advantageous to provide the optional site plan or site coordinates as
explained below.
For each chemical, indicate at a minimum the building or lot. Addition-
ally, where practical, the room or area may be indicated. You may
respond in narrative form with appropriate site coordinates or abbrevia颅
tions.
If the chemical is present in more than one building, lot, or area
location, continue your responses down the page as needed. If the
chemical exists everywhere at the plant site simultaneously, you may
report that the chemical is ubiquitous at the site.
Optional attachments: If you choose to attach one of the following,
check the appropriate Attachments box at the bottom of the Tier Two
form.
a. A site plan with site coordinates indicated for buildings, lots,
areas, etc., throughout your facility.
b. A list of site coordinate abbreviations that correspond to build
ings, lots, areas, etc. throughout your facility.
c. A description of dikes and other safeguard measures for storage
locations throughout your facility.
EXAMPLE:
You have benzene in the main room of the main building, and in
tank 2 in tank field 10. You attach a site plan with coordinates as
follows: main building = G-2. tank field 10 = B-6. Fill in the
Storage Location as follows:
B-6 ( Tank 2 ) G-2 ( Main Room )
CONFIDENTIAL INFORMATION
Under Title III. Section 324, you may elect to withhold location
information on a specific chemical from disclosure to the public, If you
choose to do so:
鈥nter the word 鈥渃onfidential鈥? in the Non-Confidential Location section
of the Tier Two form on the first line of the storage locations.
鈥? On a separate Tier Two Confidential Location Information Sheet,
enter the name and CAS number of each chemical for which you are
keeping the location confidential.
鈥? Enter the appropriate location and storage information, as described
above for non-confidential locations.
鈥? Attach the Tier Two Confidential Location Information Sheet to the
Tier Two form. This separates confidential locations from other
information that will be disclosed to the public.
CERTIFICATION
Instructions for this section are included on page one of these
instructions.
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