Missouri Emergency Response Commission (1) - Department of Public Safety - PO Box 3133 Jefferson City, MO 65102
TIER TWO - Emergency and Hazardous Chemical Inventory (General Information)              
Page  1  of    
Important: Please read all instructions before completing form[  ]Check if information below is identical to the information submitted last year
Report period from January 1 to December 31, ________
Facility Identification (2a) - Facility Location
Facility Name:   
Street Address:
City: State: Zip:
Phone: Fax:  
E-Mail: County:

Mailing Address:
Name:   
Mail Address:
City: State: Zip:

SIC Code:
Dun & Bradstreet Number:
NAICS Code:
TRI Number:
Latitude: D: M: S:
Longitude:
D: M: S:

Fire Department with Jurisdiction

Are Any Explosive Listed?
Land Owner:
Owner/Operator Information (2b)
Name:   
Mail Address:
City: State: Zip:
Phone: Fax:  
E-Mail:

Regulatory point of Contact Information (2c)
Name:   
Mail Address:
City: State: Zip:
Phone: Fax:  
E-Mail:

Emergency Contact Information (2d)
Name:
Title:
Phone:
24 hr. Phone:
Name :
Title:
Phone :
24 hr. Phone:
Submission for Reporting Year:
Certification (Read and sign after completing all sections)
I certify under penalty of law that I have personally examined and am familiar with the information submitted in pages one through 
 2 , 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.
Optional Attachments
[   ] 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
Name and official title of owner/operator OR owner/operator’s authorized representative
Name
__________________________________    Title _________________________    Signature___________________________________ Date Signed __________________
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