302 Emergency Planning Notification {52016}

302 EMERGENCY PLANNING NOTIFICATION State Form 52016 (1-05) Indiana Department of Environmental Management Indiana Emergency Response Commission Read Instruction found after this form before completing this form 1. Facility Information: ID Number Name Street Address City Telephone ____________________________ ____________________________________________________________ ____________________________________________________________ ____________________ County ____________ ZIP code _______ ___________________ E-mail ______________________________ 2. Contact Information: Contact Person Address City Telephone ____________________________________________________________ ____________________________________________________________ (if different than facility address) ___________________ ___________________ County E-mail ____________ ZIP code _______ ______________________________ 3. Extremely Hazardous Substance (EHS) Storage Information: EHS Name _______________________ Maximum quantity stored at any time Is the facility a planning facility for the first time? Date the EHS was initially brought on site Calendar years facility reported as a planning facility CAS Number _____________ _________________________ (pounds) Yes No ______________________________ ______________________________ 4. Certification I have determined that the above facility does store an EHS as defined by SARA Title III above the TPQ and therefore is subject to Section 302 of EPCRA. _________________________________ Name of official filling out form _________________________________ Title ______________________________ Signature of official ______________________________ Date (month, day, year) American LegalNet, Inc. www.FormsWorkflow.com 302-Instructions Section 302 of SARA Title III outlines the requirements if an EHS is present at a facility in a quantity greater than or equal to the established TPQ. The presence of EHSs in such quantities designates a facility as a planning facility. The facility must, therefore, submit written notification within 60 days of storing an EHS to the following: · IDEM Indiana Emergency Response Commission Attn: Tier II 100 N. Senate Ave. Indianapolis, IN 46204 Facility Information a. 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. Name of the Facility--Enter the actual name of the facility, generally the name appearing on an exterior sign at the facility. 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. 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. County--Provide the name of the county in which the facility is located. This must be consistent with the location of the city. 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. Telephone--Provide the facility telephone number. E-mail--Provide email address for the facility. LEPC--County where the facility is located 1 b. c. d. e. f. g. h. 2 Contact Information a. Contact Person--Enter the name of the designated contact person for the facility. b. c. d. Address--Provide the address of the contact person named above if this address is different from the facility address. Telephone--Provide the telephone number for the contact person. This should be a 24 hour contact number. E-mail--Provide email address of the contact person. 3 EHS Storage Information a. b. c. d. 4. EHS Name--Provide the common name or trade name of the substance or mixture. Storage Quantity--Provide the maximum quantity stored at the facility at any time during the year. Date of Introduction--Enter the date the EHS was first brought on site. This is the date the facility became a planning facility. Reporting--Provide each calendar year this facility filed notification with the SERC and appropriate LEPC. Certification--Please provide name of the facility official filling out this form, their professional title and signature, and the date of completion. American LegalNet, Inc. www.FormsWorkflow.com