SARA -Title III

                                                                 Section 311 - Reporting Form

Facility Name:                                                                    Community Right-To-Know#                                  

Mailing Address:                                                                                                   

City, State, Zip:                                                                                                           County:             

Physical Address:                                                                                                 

(if different from

mailing address)                                                                                                   

Facility Representative:                                                                Phone: ___________________________________

It is the facility's option to use this form or to submit MSDSs for certain chemicals at your facility under SARA, Section 311; however, the list must be grouped in the five Hazard Categories listed below.  This is a one-time reporting requirement.  However, if there is a significant change in the status of a reportable chemical (i.e., a change in the MSDS) or a new chemical that is covered is acquired, a facility must submit an MSDS or a new list for those chemicals within three months.

Is this an initial submittal or an update?                              Initial                    Update

A copy of this submittal must be sent to:  1) local fire department; 2) Local Emergency Planning Committee; and, 3) State Emergency Response Commission.

You must report on:          1)       the Extremely Hazardous Substances at or in excess of the Threshold Planning Quantity, or 500 pounds, whichever is less, and

                              2)       any of the hazardous chemicals in excess of 10,000 pounds.

Check off all of the physical and health categories that apply.  The categories are not mutually exclusive; a chemical can fall under several categories.  The hazardous categories are as follows:

                                                                      F     -    Fire Hazard

                                                                      P     -    Sudden Release of Pressure

                                                                      R    -    Reactivity

                                                                      AH  -    Immediate (Acute) Health Hazard

                                                                      CH  -    Delayed (Chronic) Health Hazard

                                                                                     (Over)

                                                                           HAZ CATEGORIES