SITE SPECIFIC CHEMICAL PLAN Hazardous Materials Management Plan - DOC

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					 Company Name:




SITE SPECIFIC HAZARDOUS
     CHEMICAL PLAN
HAZARDOUS MATERIALS
 MANAGEMENT PLAN


                    COMPANY NAME
                 DIVISION OR FACILITY
                   STREET ADDRESS
                    CITY, STATE ZIP


             Prepared by:               Date:




                            -1-
    Company Name:


                                          SECTION ONE
                        GENERAL FACILITY INFORMATION
  The numbers located to the right of the text boxes in this form correspond to numbers in the instruction
       booklet. Additional information about each text box can be found in the instruction booklet.

                                                LONGITUDE                            LATITUDE                1.1
FACILITY
LANDING SITE

                                         PREVAILING WINDS:                                                   1.2


                                             BUSINESS TYPE:                                                  1.3


                                     FACILITY STREET ADDRESS:
                                        (Do not use P. O. Box or mail drop)                                  1.4


                                    FACILITY MAILING ADDRESS:                                                1.5

                   HAZARDOUS MATERIALS DATA STORAGE BOX LOCATION:                                            1.6

                                         KEY BOX LOCATION:                                                   1.7

                               SUPPLEMENTAL PLANS FOR FACILITY                                               1.8


                                      SITE ACCESS LOCATIONS:
                                                                                                             1.9

                          AVERAGE NUMBER OF OCCUPANTS PER SHIFT
                                                                                                             1.10
HRS OF              MON       TUES    WED      THUR     FRI                          SAT          SUN
OPERATIONS




                                                      -2-
    Company Name:
          ITEM                                          DESCRIPTION     1.11
BUILDING TYPE

ROOF TYPE
BUILDING DIMENSIONS

STORIES

VENTILATION
STAIRWELLS
                                        UTILITIES
GAS                          YES / NO        LP _____    NATURAL ____
CUTOFF LOCATION
ELECTRICAL BREAKER BOX
OTHER
ONSITE SECURITY

                       NFPA 704 PLACARD (WORST CASE/ GENERAL):
                                                                        1.12
                      RED ____ BLUE ____ YELLOW ____ WHITE_____

                           GENERAL SITE CHARACTERISTICS
SOIL TYPE                                                               1.13
SLOPE
WATER SUPPLIES
DRAINAGE PATTERNS
FLOOD PREVENTION

                       FIRE DETECTION AND SUPPRESSION SYSTEMS           1.14
ANNUNCIATOR PANEL (FIRE ALARM)




DETECTION SYSTEM




SPRINKLER SYSTEM



- CONNECTION
STANDPIPE
- CONNECTION
HYDRANT LOCATION(S)
DRY HYDRANTS
DRAFT PONDS
FIRE EXTINGUISHERS
EXPECTED CONTAINMENT AREA
FOR FIRE SUPPRESSION RUNOFF
DATE OF LAST FIRE INSPECTION




                                          -3-
     Company Name:
            PROXIMITY OF HIGH RISK EXPOSURES (SCHOOLS, DAY CARE, HOSPITALS, ETC):
                                                                                                                    1.15

                   WATERSHED                                                 WATER BASIN
                                                                                                                    1.16

       INFORMATION REQUESTED IN TEXT BOX 1.17 IS FOR NCDA & CS CONTINGENCY PLANS ONLY


                                               PESTICIDES
                                                                                                                    1.17
           PRODUCT                           WEIGHT (POUNDS)                              GALLONS
          FUNGICIDES
         INSECTICIDES
          HERBICIDES
          FUMIGANTS

LAND USE FOR IMMEDIATELY ADJACENT PROPERTY OR .25 OF A MILE FOR NCDA & CS
FACILITIES (buildings, roadways, crops, livestock (species and numbers), location of wells, flood plains, surface   1.18
water bodies AND any other land uses)
      ACRES                                                     USE




                                                    NOTES                                                           1.19




                                                      -4-
    Company Name:


                                 SECTION TWO
                         EMERGENCY NOTIFICATIONS

                         24 HOUR EMERGENCY CONTACT NUMBER:                     2.1


PRIMARY                 TITLE           OFFICE #     HOME #          PAGER #
                                                                               2.2
EMERGENCY
COORDINATOR

ALTERNATE               TITLE           OFFICE #     HOME #          PAGER #


ALTERNATE               TITLE           OFFICE #     HOME #          PAGER #




NOTES (ADDITIONAL CONTACTS)                                                    2.3




                        SECTION THREE
         DIRECTION & CONTROL OF RESPONDING AGENCIES
  IN ACCORDANCE WITH THE WAKE COUNTY INCIDENT COMMAND MASTER PLAN


   PRIMARY COMMAND POST LOCATION             SECONDARY COMMAND POST LOCATION
                                                                               3.1


    PRIMARY STAGING AREA LOCATION            SECONDARY STAGING AREA LOCATION   3.2


               FACILITY EMERGENCY RESPONSE GROUPS RESPONSIBILITIES             3.3
FIRE BRIGADE
HAZMAT ERT
SECURITY
FIRST AID
RESPONDERS

            FIRE DEPARTMENT & HAZMAT RESPONSE TEAM CAPABILITIES
                                                                               3.4
PRIMARY FD
MUTUAL AID FD
HAZMAT



                                       -5-
     Company Name:

                      LAW ENFORCEMENT ORGANIZATIONS RESPONSIBILITIES                                                3.5
PRIMARY LEO
MUTUAL AID LEO

                         EMERGENCY MEDICAL SERVICES RESPONSIBILITIES
                                                                                                                    3.6
EMERGENCY
MEDICAL SERVICE
HOSPITAL

               EMERGENCY MANAGEMENT STAFF DUTY OFFICER RESPONSIBILITIES                                             3.7
County public safety will report to the Command Post. Act as agency liaison officer to coordinate with outside
agencies. Notify and coordinate local/state/federal resources. Provide computer database and establish protective
actions for the general public. Ensure proper reporting and notifications to local/state/federal agencies.

                         FIRE SERVICE STAFF DUTY OFFICER RESPONSIBILITIES                                           3.8
Fire Service will report to the Command Post and assist IC in coordination of fire departments from Wake and
adjoining counties. Coordinate equipment; move and assist in equipment staging. Investigate fire origin and
provide additional fire related resources.

              PUBLIC INFORMATION OFFICER (PIO) RESPONSIBILITIES                                                     3.9
EMERGENCY SECTOR PIO
CORPORATE SECTOR PIO

                                                     OTHER                                                          3.10




                                                       -6-
Company Name:


                          SECTION FOUR
           FACILITY EVACUATION INFORMATION


                EMPLOYEE ACCOUNTABILITY COORDINATOR
                                                        4.1


            SUMMARY OF FACILITY EVACUATION PROCEDURES
                                                        4.2




                  ON-SITE EMPLOYEE GATHERING SITE(S)    4.3




                 OFF-SITE EMPLOYEE GATHERING SITE(S)    4.4




                                 -7-
      Company Name:


                                                   SECTION FIVE
              HAZARDOUS MATERIALS OPERATING PROCEDURES


STANDING OPERATING PROCEDURES HAZARDOUS MATERIALS HANDLING
(Including receiving, sampling, labeling, material flow, waste)                                                                       5.1




SEPARATION OF MATERIALS
For each storage facility describe the method used to separate and protect chemicals                                                  5.2
Describe Control Areas and containment
Control area is defined as spaces within a building which are enclosed and bounded by exterior walls, fire walls, fire barriers and
roofs, or a combination thereof, where quantities of hazardous materials not exceeding the maximum allowable quantities per
control area are stored, dispensed, used or handled.



Control Area #1




Control Area #2




Control Area #3




                                                               -8-
     Company Name:
WASTE HANDLING PROCEDURES
                                                                         5.3
(method use, permits, program)




              SPECIALIZED HAZMAT INSTRUMENTATION/ MONITORING PROGRAMS
                                                                        5.4
Type
Testing
Maintenance




                          DESIGNATED PRIVATE CLEAN-UP CONTRACTOR


                           ON CALL EQUIPMENT/ SUPPLY RESOURCES




                          FACILITY TECHNICAL ASSISTANCE RESOURCES       5.5


                                 EMPLOYEE TRAINING LEVEL                5.6




RECORD KEEPING
(inspection, checklist)                                                 5.7




                                          NOTES                         5.8




                                           -9-
    Company Name:


                EMERGENCY TELEPHONE NUMBERS                                  5.9

WAKE COUNTY EMERGENCY                         911

LOCAL EMERGENCY PLANNING COMMITTEE            919-856-6480

CHEMTREC                                      800-424-9300

CAROLINAS POISON CENTER                       800-848-6946

STATE WARNING POINT                           919-733-3861

NATIONAL RESPONSE CENTER                      800-424-8802

PESTICIDE SECTION, NCDA & CS                  919-733-3556 OR 919-733-3861

(ANY FACILITY SPECIFIC EMERGENCY NUMBERS)




                     INFORMATIONAL TELEPHONE NUMBERS                         5.10
                         (NON-EMERGENCY NUMBERS)
WAKE COUNTY PUBLIC SAFETY
     - EMERGENCY MANAGEMENT           919-856-6480
     - FIRE/RESCUE                    919-856-6340
     - EMERGENCY MEDICAL SERVICES     919-856-6020

WAKE COUNTY FIRE MARSHALS OFFICE              919-856-6340
 (INSPECTION AUTHORITY FOR KNIGHTDALE,
 ROLESVILLE, WENDELL AND UNINCORPORATED
 AREAS)

INCORPORATED AREA FIRE DEPARTMENTS

APEX                                          919-362-4001
CARY                                          919-469-4057
FUQUAY                                        919-552-1413
GARNER                                        919-772-4688
HOLLY SPRINGS                                 919-552-6221
KNIGHTDALE                                    919-266-2111
MORRISVILLE                                   919-469-2156
RALEIGH                                       919-831-6392
ROLESVILLE                                    919-556-2064
WAKE FOREST                                   919-554-6140
WENDELL                                       919-365-3635
ZEBULON                                       919-269-6487

UNINCORPORATED AREA FIRE DEPARTMENTS

 CONTACT WAKE COUNTY PUBLIC SAFETY-
 FIRE/RESCUE DIVISION                         919-856-6340




                                          - 10 -
    Company Name:


                                                     SECTION SIX
                                              CHEMICAL INVENTORY
                                 NAME (LIST SEPARATE FOR EACH MAJOR STORAGE LOCATION)
                                                                                                             6.0
CHEMICAL NAME   CAS #UN/NA   MANUFACTURER   STORAGE CONDITION      STORAGE              AMOUNTS   NFPA   HAZARD
                                            AND STATE (S, L, G)    LOCATION                        704    CLASS




                                                          - 11 -
     Company Name:

                                                SECTION SIX
       STANDARD OPERATING PROCEDURE FOR SPILL CLEANUP


Fill out this text box ONLY if you do not maintain any EHS chemicals in quantities at or above their                       6.1
Threshold Planning Quantity (TPQ). You must complete sections 6.3 - 6.23 for all EHS chemicals maintained,
stored or held at your facility in quantities at or above the TPQ. For facilities that do not maintain quantities of EHS
materials at or above the TPQ, use this section to describe how the following spills are handled (if applicable):
         (1) Spills under 5 gallons
         (2) Spills 5 gallons or over
         (3) Leaks of any chemical stored in the gaseous form (include detection procedures).




SPILL CONTINGENCY PLAN
                                                                                                                           6.2




                                                        - 12 -
      Company Name:

      EHS #: **



                          SECTION SIX
 CHEMICAL SPECIFIC SPILL/ RELEASE/ HEALTH CONTINGENCY FOR an
                 EHS in phase (check all that apply)

                                      ( ) solid        ( ) liquid         ( ) gas


                                        CHEMICAL SPILL/ RELEASE FOR                                                            6.3
TRADE NAME(S):
COMMON
NAME:
CAS #

                                       PRIMARY STORAGE LOCATION(S)                                                             6.4


                              GENERAL IMPACT ASSUMPTIONS IF RELEASED                                                           6.5


                                ESTIMATED ROUTE OF TRAVEL ON RELEASE                                                           6.6


                 SPECIAL PROTECTION PROBLEMS (THIS PRODUCT - IN THIS AREA)                                                     6.7


                             RECOMMENDED INITIAL RESPONDER PPE LEVEL                                                           6.8


SPECIALIZED FACILITY                                                                                                           6.9
MONITORING EQUIPMENT
SPECIALIZED EQUIPMENT
FOR THIS PRODUCT
ONSITE RESPONDERS
LEVEL OF HM TRAINING
NUMBER / SHIFT
RESPONDER PPE ON SITE

                                           BEST CONTAINMENT AREA
                                                                                                                               6.10

                                   SUGGESTED DECONTAMINATION AREA
                                                                                                                               6.11


                                 ADDITIONAL COMPLICATIONS FROM FIRE                                                            6.12


                                                          - 13 -
**Complete a separate form for each EHS at your facility. Each EHS has its own identification number. For instance, place
a “1” in the section header box for all pages describing the first EHS. Place a “2” in the section header box for the second
EHS, and so on.
      Company Name:

      EHS #: **


                                  SPILL CONTROL (LESS THAN 5 GALLONS)                                                          6.13


                                   SPILL CONTROL (5 GALLONS OR MORE)                                                           6.14


                DETECTION OF LEAKING FUMIGANTS (if this EHS is maintained as a gas)                                            6.15


                                 ANTICIPATED HEALTH IMPACTS

                                   MAJOR HEALTH THREATS OF PRODUCT                                                             6.16


            HEALTH THREAT IMPACT ASSUMPTIONS / EXPECTATIONS UPON RELEASE                                                       6.17


                       GENERAL SIGNS AND SYMPTOMS OF PRODUCT EXPOSURE                                                          6.18


                               EMERGENCY FIRST AID RECOMMENDATIONS                                                             6.19


                                  CONTAMINATED VICTIM HOLDING AREA                                                             6.20


                                      SUGGESTED MEDICAL TRIAGE SITE                                                            6.21


                    ADDITIONAL MEDICAL SUPPORT AVAILABLE (ON or OFF SITE)                                                      6.22


                                                   PLUME MODEL                                                                 6.23


                                               Not mandatory, but helpful




                                                          - 14 -
**Complete a separate form for each EHS at your facility. Each EHS has its own identification number. For instance, place
a “1” in the section header box for all pages describing the first EHS. Place a “2” in the section header box for the second
EHS, and so on.
      Company Name:

             SPILL CONTROL EQUIPMENT                                NUMBER (or range)
                                                                                        6.24
* PERSONAL PROTECTIVE EQUIPMENT:
   Class A suits,
   Class B suits,
   Training suits
Suit Test Kit,
Self-Contained Breathing Apparatus, 30 minute air supply
per unit
Air-purifying, full face respirators, total
Air-purifying cartridges for respirators
           *Ammonia - total
           *Acid/organic vapors/dust - total
Rubber boots (over the shoe), pair
Neoprene gloves, 18 inch, pair
Chemical goggles (fog free), total
Face shields, total
Gas detector – ie samples for: Ammonia, HCL, Methane,
Propane, Methanol,
Acetylene, Hydrogen, and general sensing
* SPILL CONTAINMENT SUPPLIES:
Chemical sponges,
Kimtex towels,
Oil boom,
Drain guard mat,
Liquid absorbent pillows,
Spill pads,
Liquid absorbent,
Oil sorbent compound,
Acid neutralizer compound,
Caustic neutralizer compound,
Small absorbent kit for acid spills,
Small absorbent kit for caustic spills,
"Kiddie pools" for decon
Spray pumps, 5 gallon
* TOOLS AND EQUIPMENT
ABC fire extinguisher, 10 lbs., total
Shovel, 48" and round blade, total
Shovel, 36" and flat blade, polypropylene, total
Sledge hammer, total
Pry bar tool, total
Squeegee, 18" head, total
Mop, total
Push broom, 30" head, total
Bucket and wringer, total
Counter brush, 8", total
Rope, ½" x 465'
First aid kit, 25 person, total
Generator, 2200 watts, 5 HP motor, 2-120V outlets
Electronic blood pressure monitor, total
Flashlights, total
Stand up portable lights, total
* OTHER
Ie clean-up kit for 15 gallon spills




                                                           - 15 -
     Company Name:

MAPS 8 1/2 BY 11 inch
                                                                                                        6.25
  1. General Site Map Overview
  (Immediately adjacent property or .25 miles (identify items listed in 1.18), drainage, wells, sewers,
  parking lots, chemical loading areas)




                                                   - 16 -
     Company Name:

MAPS 8 ½ by 11 inch
  2. Facility Use/Storage (Identify each facility with Building ID number/name)                               6.26
        Provide drawings of the use/storage of chemicals, gas lines, low-pressure fuel lines, cutoff valves




                                                          - 17 -
     Company Name:

MAPS
  3. Tank farm layout/utility yard/storage building                               6.27
       Identification, emergency equipment, monitoring, waste, and 704 placards
       Tank sizes, pipes and valves, on and off switches




                                                     - 18 -
    Company Name:

MAPS
  4. Control Areas (Building/warehouse drawings)
       flammable storage rooms, fire protection, emergency signage, emergency equipment,   6.28
       separation of chemical, control areas marked, isolation and mitigation devices




                                                     - 19 -
   Company Name:

MAPS
  5.   SITE RUNOFF CONTROL:
                                       6.29




                              - 20 -
          WAKE COUNTY
LOCAL EMERGENCY PLANNING COMMITTEE
                            C/O WAKE COUNTY EMERGENCY MANAGEMENT
                               A DIVISION OF THE DEPARTMENT OF PUBLIC SAFETY


                             REPORTABLE QUANTITY FORM
Notice to Spillers:
Page 1 of 2

Section 304 of the Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA) requires
facilities that use, produce or store certain listed hazardous substances to immediately report accidental
releases of those materials. The facility must immediately report the release to the Local Emergency Planning
Committee (LEPC), the State Emergency Response Commission (SERC), and the National Response Center
(NRC). The agencies that this form must be sent on are listed on the next page.

On-scene responders have indicated that you are required to make a written legal notification of an incident at
your facility. This form must be completed and returned to the appropriate agencies immediately. The lists of
chemical subject to Section 304 notification and the corresponding RQ are found in 40 CFR Table 302.4

Facility Name __________________________________________________________________________
Release Occurred At ______________________________________________________________________
Contact Person __________________________________________ Phone __________________________

Type of Release:      [ ] Chemical Release in Excess of Threshold RQ        [ ] Release of Unknown Chemicals
                      [ ] Release with a potential for off-site exposure    [ ] Other______________________

Name of Chemical(s) and Quantity Released:
_________________________________________________________ Amt.__________________________
_________________________________________________________ Amt.__________________________
Time and Duration of Release: ____________________________________________________________
_______________________________________________________________________________________

The Release was:         [ ] air          [ ] land                 [ ] surface water     [ ] ground water

Anticipated acute or chronic health risks: __________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Medical Attention Required: [ ] Yes (statement attached)                   [ ] No

Precautions:  __________________________________________________________________________
________________________________________________________________________________________

Evacuation Information: _________________________________________________________________
_______________________________________________________________________________________

Response Actions: _______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
**For questions or to make at notification to Wake County LEPC call 919-856-6480 or fax 919-856-7046**

                                                      - 21 -
                                                              Page 2 of 2
Mailing Addresses and Fax Numbers
1.     WAKE CO LEPC
       WAKE CO EMERGENCY MANAGEMENT
       PO BOX 550
       RALEIGH NC 27602
       919-856-6480
       919-856-7046 fax

2.   NC SERC
     NC DIVISION OF EMERGENCY MANAGEMENT
     116 W JONES ST
     RALEIGH NC 27603
     919-733-3867
     919-733-7554

3.   NATIONAL RESPONSE CENTER
     800-424-8802
     (Reports taken telephonically)

4.   FIRE DEPARTMENT HAVING JURISDICTION OVER YOUR FACILITY
     (See section 5.10 for contact numbers)




                                      - 22 -