Section H4 Maintenance of Records

1. Fill out Items 1 through 11 and sign the declaration
2. Only Part A of this section is required to be updated and submitted annually, or within 30 days of a change.

1. Provide a site plan on 8¹/₂-by 11-inch (215 mm by 279 mm) paper, using letters on the top and bottom margins and numbers on the right and left side margins, showing the location of all buildings, structures, chemical loading areas, parking lots, internal roads, storm and sanitary sewers, wells, and adjacent property uses. Indicate the approximate scale, northern direction and date the drawing was completed.
2. List all special land uses within 1 mile (1.609 km).

Fill out all appropriate information.

1. You must complete a separate inventory statement for all waste and nonwaste hazardous materials. List all hazardous materials in alphabetical order by hazard class.

2. Inventory Statement Instructions:

   Column               Information Required
   1. Provide hazard class for each material.
   2. Nonwaste. Provide the common or trade name of the regulated material. Waste. In lieu of trade names, you may provide the waste category.
   3. Provide the chemical name and major constituents and concentrations, if a mixture.
   4. Enter the chemical abstract service number (CAS number) found in 29 C.F.R. For mixtures, enter the CAS number of the mixture as a whole if it has been assigned a number distinct from its constituents. For a mixture that has no CAS number, leave this item blank or report the CAS numbers of as many constituent chemicals as possible.

   5. Enter the following descriptive codes as they apply to each material. You may list more than one code, if applicable.

      P	=	Pure
      M	=	Mixture
      S	=	Solid
      L	=	Liquid
      G	=	Gas

   6. Provide the maximum aggregate quantity of each material handled at any one time by the business. For underground tanks, list the maximum volume [in gallons (liters)] of the tank.

      1. 6.1 Enter the estimated average daily amount on site during the past year.

   7. Enter the units used in Column 6 as:

      LB	=	Pounds
      GA	=	Gallons
      CF	=	Cubic Feet

   8. Enter the number of days that the material was present on site (during the last year).

   9. Enter the storage codes below for type, temperature and pressure.

      
      
      • Type

        A	=	Aboveground Tank
        B	=	Belowground Tank
        C	=	Tank inside Building
        D	=	Steel Drum
        E	=	Plastic or Nonmetallic Drum
        F	=	Can
        G	=	Carbon
        H	=	Silo
        I	=	Fiber Drum
        J	=	Bag
        K	=	Box
        L	=	Cylinder
        M	=	Glass Bottle or Jug
        N	=	Plastic Bottles or Jugs
        O	=	Tote Bin
        P	=	Tank Wagon
        Q	=	Rail Car
        R	=	Other

      • Temperature

        4	=	Ambient
        5	=	Greater than Ambient
        6	=	Less than Ambient, but not Cryogenic [less than -150°F (-101.1°C)]
        7	=	Cryogenic conditions [less than -150°F (-101.1°C)]

      • Pressure

        1	=	Ambient (Atmospheric)
        2	=	Greater than Ambient (Atmospheric)
        3	=	Less than Ambient (Atmospheric)

   10. For each material listed, provide the Superfund Amendments and Reauthorization Act (SARA) hazard class as listed below. You may list more than one class. These categories are defined in 40 C.F.R. 370.3.

       • Physical Hazards

         F	=	Fire
         P	=	Sudden Release of Pressure
         R	=	Reactivity

       • Health Hazards

         I	=	Immediate (Acute)
         D	=	Delayed (Chronic)

   11. Waste Only. For each waste, provide the total estimated amount of hazardous waste handled throughout the course of the year.

Fill out Items 1 through 6, or provide similar information for each storage area shown on the facility map. Use additional sheets as necessary.

1. Complete a separate page for each underground tank, sump, vault, below-grade treatment system, etc.
2. Check the type of tank and method(s) that applies to your tank(s) and piping, and answer the appropriate questions. Provide any additional information in the space provided or on a separate sheet.

Check all that apply and list the associated wastes for each method checked.

Include a brief description of your inspection procedures. You are also required to keep an inspection log and recordable discharge log, which are designed to be used in conjunction with routine inspections for all storage facilities or areas. Place a check in each box that describes your forms. If you do not use the sample forms, provide copies of your forms for review and approval.

1. This plan should describe the personnel, procedures and equipment available for responding to a release or threatened release of hazardous materials that are stored, handled or used on site.
2. A check or a response under each item indicates that a specific procedure is followed at the facility, or that the equipment specified is maintained on site.
3. If the facility maintains a more detailed emergency-response plan on site, indicate this in Item 5. This plan shall be made available for review by the inspecting jurisdiction.

1. This plan should describe the basic training plan used at the facility.
2. A check in the appropriate box indicates the training is provided or the records are maintained.
3. If the facility maintains a more detailed emergency-response training plan, indicate this in Item 4. This plan shall be made available for review by the inspecting jurisdiction.

1. Business Name: __________________________________________________________
2. Address: ________________________________________________________________

3. Declaration:

   Under penalty of perjury, I declare the above and subsequent information, provided as part of the hazardous materials inventory statement, is true and correct.

   Signature: _________________________________________________Date: _____________________________________

   Print Name: _______________________________________________Title: ______________________________________

   (Must be signed by owner/operator or designated representative)

Storage Area Identification (as shown on facility map):_____________________________________

1. Storage Type:

   ___________ Original Containers	___________ Safety Cans
   ___________ Inside Machinery	___________ Bulk Tank
   ___________ 55-gallon (208.2 L)	___________ Outside Barrels
   Drums or Storage Shed
   ___________ Pressurized Vessel

   ___________Other:_____________________________________________________________________________________

   ______________________________________________________________________________________________________

   ______________________________________________________________________________________________________

2. Storage Location:

   ___________ Inside Building		___________ Outside Building
   ___________ Secured

3. Separation:

   ___________ All Materials	___________ One-hour Separation
   ___________ Compatible Wall/Partition
   ___________ Separated by 20 Feet (6096 mm)	___________ Approved Cabinets

   ___________Other:_____________________________________________________________________________________

   ______________________________________________________________________________________________________

   ______________________________________________________________________________________________________

4. Secondary Containment:

   ___________ Approved Cabinet		___________ Secondary Drums
   ___________ Tray		___________ Bermed, Coated Floor
   ___________ Vaulted Tank		___________ Double-wall Tank

   ___________Other:_____________________________________________________________________________________

   ______________________________________________________________________________________________________

   ______________________________________________________________________________________________________

5. Monitoring:

   ___________ Visual

   ___________ Continuous

   ___________Other:_____________________________________________________________________________________

   ______________________________________________________________________________________________________

   ______________________________________________________________________________________________________

   Attach specifications if necessary

6. Monitoring Frequency:

   ___________ Daily ___________ Weekly

   ___________Other:_____________________________________________________________________________________

   ______________________________________________________________________________________________________

   ______________________________________________________________________________________________________

   Attach specifications if necessary

Tank Area Identification (as shown on facility map): ___________________________________________

1. _____ Backfill Vapor Wells

   Model and Manufacturer:______________________________________________________________________________________________________

   Continuous or Monthly Testing:____________________________________________________________________________

2. _____ Groundwater Monitoring Wells
3. _____ Monthly Precision Tank Test

4. _____ Piping—

   Monitoring Method:_____________________________________________________________________________________

   Frequency:_____________________________________________________________________________________

5. _____ Other: _________________________________________________________________________________________

Tank Area Identification (as shown on facility map):_____________________________________________________________

1. Method of monitoring the annular space: ___________________________________________________________________

2. Frequency:

   _________ Continuous

   _________ Daily

   _________ Weekly

   _________ Other: _______________________________________________________________________________________

3. List the type of secondary containment for piping: _______________________________________________________________________________________________________________________________

   ______________________________________________________________________________________________________

4. List the method of monitoring the secondary containment for piping: _____________________________________________

5. Are there incompatible materials within the same vault?

   _______ Yes

   _______ No

   If yes, how is separate secondary containment provided?_________________________________________________________

   ______________________________________________________________________________________________________

   Note: If you have continuous monitoring equipment, you shall maintain copies of all service and maintenance work. Such reports shall be made available for review on site, and shall be submitted to the fire prevention bureau upon request.

   Attach additional sheets as necessary.

Description of our inspection program: ______________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

_____We will use the attached sample forms in our inspection program.

_____We will not use the sample forms. We have attached a copy of our own forms.

1. In the event of an emergency, the following shall be notified:

   1. On-site Responders:

      Name:	Title:	Home Number:
      ____________________________	____________________________	____________________________
      ____________________________	____________________________	____________________________

   2. Method of Notification to Responder:

      _____ Automatic Alarm	_____Phone
      _____ Manual Alarm	_____Verbal
      _____ Other: ___________________________________________________________________________________________
      _______________________ _______________________________________________________________________________

   3. Agency:

      Phone Number:

      Fire Department:

      California Emergency Management Agency (Cal EMA):

      Other:

      ______________________________________________________________________________________________________

      ______________________________________________________________________________________________________

   4. Designated Local Emergency Medical Facility:

      Name:	Address:	Phone (24 hours):
      ____________________________	____________________________	____________________________

   5. Mitigation Equipment:

      1. Monitoring Devices:

         ______ Toxic or flammable gas detection

         ______ Fluid detection

         ______ Other:__________________________________________________________________________________________

         ______________________________________________________________________________________________________

1. Person responsible for the emergency-response training plan:

   Name:	Title:	Phone:
   ______________________	______________________	______________________

2. Training Requirements:

   1. All employees trained in the following as indicated:

      _____ Procedures for internal alarm/notification

      _____ Procedures for notification of external emergency-response organization

      _____ Location and content of the emergency-response plan

   2. Chemical handlers are trained in the following as indicated:

      _____ Safe methods for handling and storage of hazardous materials

      _____ Proper use of personal protective equipment

      _____ Locations and proper use of fire- and spill-control equipment

      _____ Specific hazards of each chemical to which they may be exposed

   3. Emergency-response team members are trained in the following:

      _____ Procedures for shutdown of operations

      _____ Procedures for using, maintaining and replacing facility emergency and monitoring equipment

3. The following records are maintained for all employees:

   _____ Verification that training was completed by the employee

   _____ Description of the type and amount of introductory and continuing training

   _____ Documentation on and description of emergency-response drills conducted at the facility

4. A more comprehensive and detailed emergency-response training plan is maintained on site.

   Location: ______________________________________________________________________________________________

   Responsible Person: _____________________________________________________________________________________

   Phone: ________________________________________________________________________________________________