(1) Reporting year.

(2) An indication of whether the chemical identified is being claimed as trade secret.

(3) Chemical name and CAS number (if applicable) of the chemical, or the category name.

(4) Signature of a senior management official certifying the following: pursuant to 40 CFR 372.27, “I hereby certify that to the best of my knowledge and belief for the toxic chemical listed in this statement, the annual reportable amount, as defined in 40 CFR 372.27(a), 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.”

(5) Date signed.

(6) Facility name and address.

(7) Mailing address of the facility if different than paragraph (b)(6) of this section.

(8) Toxic chemical release inventory facility identification number if known.

(9) Name and telephone number of a technical contact.

(10) The four-digit SIC code(s) for the facility or establishments in the facility until the reporting year ending December 31, 2005, for which reporting forms are due July 1, 2006. Beginning with the reporting year ending December 31, 2006, for which reporting forms are due July 1, 2007, and for each subsequent reporting year, the six-digit NAICS code(s) for the facility or establishments in the facility.

(11) Dun and Bradstreet Number of the facility.

(12) Name of the facility's parent company.

(13) Parent company's Dun and Bradstreet Number.