Missouri Emergency Response Commission - Department of Public Safety - PO Box 3133 Jefferson City, MO 65102 TIER TWO - Emergency and Hazardous Chemical Inventory (General Information)               Received By/Date      Page  1  of  2  Important: Please read all instructions before completing form     Report period from January 1 to December 31, 1999 [  ]Check if information below is identical to the information submitted last year Facility Identification (2a) - Facility Location Facility Name: XYZ Company   Street Address: 123 Progress Lane City: Jefferson City State: MO Zip: 65101 Phone: 555-555-5555 Fax: 555-555-5556  E-Mail: ceo@xyzcompany.com County:Cole Mailing Address: Name: XYZ Company    Mail Address: P.O. Box 654 City: Jefferson City State: MO Zip: 65101 SIC Code: 3210 Dun & Bradstreet Number: 789456123 NAICS Code: 12345 TRI Number: 9876543210987 Latitude: D: 111 M: 40 S: 40 Longitude: D: 32 M: 25 S: 32 Fire Department with Jurisdiction Jefferson City Fire Department #2 Are Any Explosive Listed? No Land Owner: Other Owner/Operator Information (2b) Name: John Smith   Mail Address: 1300 Superior Drive City: Jefferson City State: MO Zip: 65109 Phone: 555-444-3333 Fax: 555-444-3332  E-Mail: jsmith@xyzcompany.com Regulatory point of Contact Information (2c) Name: Walter Jonez    Mail Address: 123 Progress Lane City: Jefferson City State:MO Zip: 65101 Phone: 555-555-5555 Fax: 555-555-5556  E-Mail: wjonez@xyzcompany.com Emergency Contact Information (2d) Name: John Smith Title: President Phone: 555-444-3333 24 hr. Phone: 555-444-3333 Name : Donald Ray Title: Emergency Coordinator Phone : 555-555-5555 24 hr. Phone: 555-556-5455 Submission for Reporting Year: Initial Update 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  John Smith                          Title    Owner                 Signature                                                   Date Signed    10/10/2000

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