HAZARDOUS MATERIALS BUSINESS PLAN
San Mateo County Environmental Health Services Division 455 County Center, 4th Floor Redwood City, CA 94063 Telephone: (650) 363-4305
SAN MATEO COUNTY ENVIRONMENTAL HEALTH SERVICES DIVISION 455 COUNTY CENTER, 4th FLOOR REDWOOD CITY, CA 94063
BUSINESS ACTIVITIES
Page 1 of ___
I. FACILITY IDENTIFICATION
FACILITY ID # BUSINESS NAME
(Same as FACILITY NAME or DBA-Doing Business As) 3 1
EPA ID # (Hazardous Waste Only)
2
II. ACTIVITIES DECLARATION
NOTE: If you answer YES to any part of this form, submit the Business Owner/Operator Identification page (OES Form 2730).
Does your facility...
A. HAZARDOUS MATERIALS Have on site (for any purpose) hazardous materials at or above 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases (include liquids in ASTs and USTs)? See instructions for additional reporting criteria. B. UNDERGROUND STORAGE TANKS (USTs) 1. Own or operate underground storage tanks? 2. Intend to upgrade existing or install new USTs?
If Yes, please complete these pages of the UPCF.
Circle Yes or No YES NO HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (OES 2731)
4
YES
NO
5
UST FACILITY (Formerly SWRCB Form A) UST TANK (one per tank) (Formerly Form B) UST FACILITY UST TANK (one per tank) UST INSTALLATION - CERTIFICATE OF COMPLIANCE (one per tank)(Formerly Form C) UST TANK (closure portion--one per tank)
YES NO
6
3.
Need to report closing a UST?
YES NO
7
C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) Own or operate ASTs above the threshold below: ---single or multiple tanks with a total capacity greater than 1,320 gallons? D. HAZARDOUS WASTE 1. Generate hazardous waste? 2. 3. Recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC Section 25143.2)? Treat hazardous waste on site?
YES NO YES NO YES NO YES NO
8
NO FORM REQUIRED BY CUPA EPA ID NUMBER---provide at the top of this page RECYCLABLE MATERIALS REPORT
(one per recycler)
9 10
11
ONSITE HAZARDOUS WASTE TREATMENT - FACILITY
(Formerly DTSC Form 1772)
ONSITE HAZARDOUS WASTE TREATMENT - UNIT (one per unit)
(Formerly DTSC Forms 1772 A,B,C,D, and L)
4. 5.
Treatment subject to financial assurance requirements (for Permit by Rule and Conditional Authorization)? Consolidate hazardous waste generated at a remote site?
YES NO YES NO
12
CERTIFICATION OF FINANCIAL ASSURANCE (Formerly DTSC Form 1232) REMOTE WASTE/CONSOLIDATION SITE ANNUAL NOTIFICATION (Formerly
DTSC Form 1196)
13
6.
Need to report the closure/removal of a tank that was classified as hazardous waste and cleaned onsite?
YES NO
14
HAZARDOUS WASTE TANK CLOSURE CERTIFICATION (Formerly DTSC Form 1249)
E. LOCAL REQUIREMENTS 15 Pursuant to the California Health and Safety Code Division 20, Chapter 6.95, Section 25506, this agency must obtain consent from the business owner/operator or designated business representative in order to release chemical location information to the public. This includes, but is not limited to, chemical locations provided in the chemical description section and site maps. Please circle “Yes” or “No” to indicate whether or not this information can be released to the public and sign/print your name on the line below. Consent: Yes No Signature/Printed Name: ______________________________/______________________________
SAN MATEO COUNTY ENVIRONMENTAL HEALTH SERVICES DIVISION 455 COUNTY CENTER, 4th FLOOR REDWOOD CITY, CA 94063
BUSINESS OWNER/OPERATOR IDENTIFICATION
OES Form 2730
Page ____of ____
I. IDENTIFICATION
FACILITY ID #
1
BEGINNING DATE
100 3
ENDING DATE BUSINESS PHONE
101 102
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
BUSINESS SITE ADDRESS CITY DUN & BRADSTREET COUNTY BUSINESS OPERATOR NAME
109 104 106
103
CA
ZIP CODE SIC CODE
(4 digit #)
105 107
108
BUSINESS OPERATOR PHONE
110
II. BUSINESS OWNER
OWNER NAME OWNER MAILING ADDRESS CITY
114 111
OWNER PHONE
112
113
STATE
115
ZIP CODE
116
III. ENVIRONMENTAL CONTACT
CONTACT NAME CONTACT MAILING ADDRESS CITY
120 117
CONTACT PHONE
118 119
STATE
121
ZIP CODE
122
-PRIMARYNAME TITLE BUSINESS PHONE 24-HOUR PHONE PAGER # ADDITIONAL LOCALLY COLLECTED INFORMATION:
IV. EMERGENCY CONTACTS
123
-SECONDARY128
NAME TITLE BUSINESS PHONE 24-HOUR PHONE PAGER #
124 125 126 127
129 130 131 132 133
See Hazardous Materials Business Plan
Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE NAME OF SIGNER (print) DATE
134
NAME OF DOCUMENT PREPARER
135
136
TITLE OF SIGNER
137
SAN MATEO COUNTY ENVIRONMENTAL HEALTH SERVICES DIVISION
CERTIFIED UNIFIED PROGRAM AGENCY 455 COUNTY CENTER, 4TH FLOOR REDWOOD CITY, CA 94063
OES Form 2731
___ADD
HAZARDOUS MATERIALS INVENTORY- CHEMICAL DESCRIPTION
___DELETE ___ REVISE 200 Page ___ of ___
I. FACILITY INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3
CHEMICAL LOCATION
201
CHEMICAL LOCATION CONFIDENTIAL - EPCRA
___Yes ___No
202
FACILITY ID #
1
MAP # (optional)
203
GRID # (optional)
204
II. CHEMICAL INFORMATION
CHEMICAL NAME 205 TRADE SECRET ___Yes ___ No 206
If Subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ___ Yes ___ No 208
CAS # FIRE CODE HAZARD CLASS
209
*If EHS is “Yes” all amounts below must be in lbs. 210
HAZARDOUS MATERIAL TYPE (Check one item only) PHYSICAL STATE (Check one item only) FED HAZARD CATEGORIES (Check all that apply) AVERAGE DAILY AMOUNT UNITS* (Check one item only) STORAGE CONTAINER (Check all that apply)
___ a. PURE ___ b. MIXTURE ___ c. WASTE ___ a. SOLID ___ b. LIQUID ___ c. GAS
211 214
RADIOACTIVE LARGEST CONTAINER
___ Yes
___ No
212
CURIES
213 215
___ a. FIRE 217
___ b. REACTIVE
___ c. PRESSURE RELEASE 218
___ d. ACUTE HEALTH ANNUAL WASTE AMOUNT ___ d. TONS
___ e. CHRONIC HEALTH
216 219 221 STATE WASTE CODE DAYS ON SITE ___ q. RAIL CAR ___ r. OTHER _________________________ 220 222
MAXIMUM STORAGE AMOUNT
___ a. GALLONS
__
b. CUBIC FEET
___ c. POUNDS * If EHS, amount must be in pounds.
___ a. ABOVEGROUND TANK ___ b. UNDERGROUND TANK ___ c. TANK INSIDE BUILDING ___ d. STEEL DRUM
___ e. PLASTIC/NONMETALLIC DRUM ___ f. CAN ___ g. CARBOY ___ h. SILO ___ b. ABOVE AMBIENT
___ i. FIBER DRUM ___ j. BAG ___ k. BOX ___ l. CYLINDER
___ m. GLASS BOTTLE ___ n. PLASTIC BOTTLE ___ o. TOTE BIN ___ p. TANK WAGON
223
STORAGE PRESSURE
___ a. AMBIENT
___ c. BELOW AMBIENT
224
STORAGE TEMPERATURE
___ a. AMBIENT
___ b. ABOVE AMBIENT
___ c. BELOW AMBIENT
___ d. CRYOGENIC
225
%WT
1 226
HAZARDOUS COMPONENT (For mixture or waste only)
227
EHS
___ Yes ___ No 228
CAS #
229
2
230
231
___ Yes ___ No 232
233
3
234
235
___ Yes ___ No
236
237
4
238
239
___ Yes ___ No 240
241
5
242
243
___ Yes ___ No 244
245
If more hazardous components are present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper indicating the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION: Sign Here for EPCRA:
246
CALIFORNIA ANNOTATED SITE MAP
A B C D
Business Name: E F G
Site Address: H I J
Map #:
1
• • • • • • • •
2
3
For Site Map Scale of Map Loading Areas Parking Lots Internal Roads Storm and Sewer Drains Adjacent Property Use Locations and Names of Adjacent Streets and Alleys Access and Egress Points and Roads
4
5
For Sub-Site Map Scale of Map Location of Each Storage Area • Location of Each Hazardous Material Handling Area • Location of Emergency Response Equipment • •
6
Scale: 1” = _____ Ft.
↑ North
7
HAZARDOUS MATERIALS BUSINESS PLAN
SPILL PREVENTION, EMERGENCY RESPONSE, TRAINING and CLOSURE PLAN
Business Name: ____________________________________________ Business Address: __________________________________________ In addition to the general business, chemical inventory and site map information, the San Mateo County Environmental Health Division (Division) requires completion of the following sections pertaining to spill prevention, emergency response, employee training and site closure. These sections contain specific elements pertaining to the Hazardous Materials Business Plan, the hazardous waste contingency plan, stormwater pollution prevention, and underground storage tank (UST) monitoring. SPILL PREVENTION PLAN 1. Describe how hazardous materials are handled, stored and monitored to prevent or minimize a spill or release from occurring (e.g., secondary containment, segregation of incompatibles, daily visual monitoring).
2. Describe operations, activities and/or storage locations where a release is most likely to occur.
3. Describe Best Management Practices (BMPs) used to reduce or eliminate illicit discharge of pollutants to the storm sewer system.
4. Describe underground storage tank and/or aboveground storage tank monitoring procedures used to prevent an unauthorized release from occurring.
EMERGENCY RESPONSE PLAN 1. Provide a list of emergency response equipment designated for a hazardous materials emergency (e.g., fire extinguishers, fire suppression systems, spill control equipment, shut-off switches, personal protective equipment, decontamination equipment, and communication and alarm systems). EQUIPMENT TYPE LOCATION CAPABILITY
2. Describe pre-emergency arrangements with local fire departments, police departments, hospitals, contractors, and other state and local emergency response agencies.
3. The definition of a release or threatened release of a hazardous material includes incidents that pose an actual or potential hazard to human health and safety, property or the environment. In the event of a hazardous materials release or threatened release, state law requires immediate verbal notification to the agencies listed below. a. Local Fire Department b. County Environmental Health c. State Office of Emergency Services (OES) Provide phone numbers other than 9-1-1 for the following: Local Fire Department Local Police Department Nearest Hospital County Environmental Health (650) 363-4305 State Office of Emergency Services (800) 852-7550 or (916) 845-8911
4. Describe procedures for notifying onsite emergency response personnel and outside agencies needed during hazardous materials emergencies (e.g., Fire, Health, Police, State OES).
5. Describe any security system or equipment that could impede site access by emergency responders.
6. Describe procedures for notification and evacuation of visitors and employees during a hazardous materials emergency. Primary and alternate evacuation routes and assembly areas must be clearly identified on the site map.
7. Describe mitigation or clean-up procedures to be implemented by onsite personnel in the event of a release, threatened release, fire or explosion involving hazardous materials. Indicate if the business has an onsite emergency response team (ERT) and if so, describe how the ERT will interact with outside emergency response agencies if additional assistance is required.
8. Describe procedures for immediate inspection, isolation, and shutdown of equipment or systems that may be involved in a hazardous materials release or threatened release.
EMPLOYEE TRAINING PLAN All employees must participate in an on-going training program that addresses proper hazardous materials handling and emergency response procedures. New hires must receive initial training and existing employees must receive annual “refresher” training. 1. Describe employee training as it pertains to the following: a. b. c. d. e. f. Safe handling and management of hazardous materials or wastes Notification and evacuation of facility personnel and visitors Notification of local emergency responders and other agencies Use and maintenance of emergency response equipment Implementation of emergency response procedures UST monitoring and release response procedures
2.
Describe documentation and recordkeeping procedures for training activities. Please note that if you generate hazardous waste at your business, you must also maintain documents onsite that indicate employee names and job titles, job descriptions, and descriptions of the type and amount of initial and refresher training.
CLOSURE PLAN Contact San Mateo County Environmental Health prior to business closure. Business closure guidelines are available upon request. 1. Describe procedures that will be implemented in the event of a full or partial site closure. Include agency notification, hazardous materials removal, hazardous waste disposal, equipment breakdown and removal, and site decontamination.
Rev.2/04