Cal. Code Regs. Tit. 19, div. 5, ch. 1, art. 3, app B
Article 3 -- Minimum Standards for Business Plans Hazardous Materials Inventory -- Instructions
I. Unified Program Consolidated Form -- Business Activities
II. Business Owner/Operator Identification
III. Hazardous Materials -- Chemical Description
IV. Annotated Site Map
Business Activities
Please submit the Business Activities page, the Business Owner/Operator Identification page, and Hazardous Materials Inventory -- Chemical Description pages for all submissions. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form (UPCF) pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3, Electronic Submittal of Information). Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated.
1. FACILITY ID NUMBER -- Leave this blank. This number is assigned by the Certified Unified Program Agency (CUPA) or Administering Agency (AA). This is the unique number which identifies your facility.
2. EPA ID NUMBER -- If you generate, recycle, or treat hazardous waste, enter your facility's 12-character U.S. Environmental Protection Agency (U.S. EPA) or California Identification number. For facilities in California, the number usually starts with the letters [] CA []. If you do not have a number, contact the Department of Toxic Substances Control (DTSC) Telephone Information Center at (916) 324-1781, (800) 61-TOXIC or (800) 61-86942, to obtain one.
3. BUSINESS NAME -- Enter the full legal name of the business. This is the same as the terms [] Facility Name [] or [] DBA -- Doing Business As [] that might have been used in the past.
103. BUSINESS SITE ADDRESS -- Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means to geographically locate the facility.
104. BUSINESS SITE CITY -- Enter the city or unincorporated area in which business site is located.
105. ZIP CODE -- Enter the zip code of business site. The extra 4 digit zip may also be added.
4. HAZARDOUS MATERIALS --
Check the box to indicate whether you have a hazardous material onsite. You have a hazardous material onsite if:
- It is handled in quantities equal to or greater than 500 pounds, 55 gallons, or 200 cubic feet of compressed gas (calculated at standard temperature and pressure),
- It is handled in quantities equal to or greater than the applicable federal threshold planning quantity for an extremely hazardous substance listed in 40 CFR Part 355, Appendix A,
- Radioactive materials are handled in quantities for which an emergency plan is required to be adopted pursuant to Part 30, Part 40, or Part 70 of Chapter 10 of 10 CFR, or pursuant to any regulations adopted by the state in accordance with these regulations.
If you have a hazardous material onsite, then you must complete the Business Owner/Operator Identification page and the Hazardous Materials Inventory -- Chemical Description page, as well as an Emergency Response Plan and Training Plan. Do not answer [] YES [] to this question if you exceed only a local threshold, but do not exceed the state threshold.
4a. REGULATED SUBSTANCES -- Refer to 19 CCR 5130.6 for regulated substances. Check the box to indicate whether your facility has CalARP regulated substances stored onsite.
5. OWN OR OPERATE UNDERGROUND STORAGE TANK (UST) -- Check the appropriate box to indicate whether you own or operate USTs containing hazardous substances as defined in Health and Safety Code (HSC) 25316. If []YES[], then you must complete one UST Facility page and UST Tank pages for each tank. You must also submit a plot plan and a monitoring program plan.
8. OWN OR OPERATE ABOVEGROUND PETROLEUM STORAGE TANK OR CONTAINER -- Check the appropriate box to indicate whether there are ASTs onsite which exceed the regulatory thresholds. (There is no UPCF page for ASTs.) This program applies to all facilities storing petroleum in aboveground tanks. Petroleum means crude oil, or any fraction thereof, which is liquid at 60 degrees Fahrenheit temperature and 14.7 pounds per square inch absolute pressure (HSC 25270.2 (g)). The facility must have a cumulative storage capacity greater than 1,320 gallons for all ASTs. NOT Subject to the Act (exemptions):
An aboveground petroleum storage tank (AST) facility with one or more of the following (see HSC 25270.2 (k)) is not subject to this act and is exempt:
- A pressure vessel or boiler which is subject to Division 5 of the Labor Code,
- A storage tank containing hazardous waste if a hazardous waste facility permit has been issued for the storage tank by DTSC,
- An aboveground oil production tank which is regulated by the Division of Oil and Gas,
- Certain oil-filled electrical equipment including but not limited to transformers, circuit breakers, or capacitors.
9. HAZARDOUS WASTE GENERATOR -- Check the appropriate box to indicate whether your facility generates hazardous waste. A generator is the person or business whose acts or processes produce a hazardous waste or who causes a hazardous substance or waste to become subject to State hazardous waste law. If your facility generates hazardous waste, you must obtain and use an EPA Identification number (ID) in order to properly transport and dispose of it. Report your EPA ID number in #2. Hazardous waste means a waste that meets any of the criteria for the identification of a hazardous waste adopted by DTSC pursuant to HSC 25141. "Hazardous waste" includes, but is not limited to, federally regulated hazardous waste. Federal hazardous waste law is known as the Resource Conservation and Recovery Act (RCRA). Unless explicitly stated otherwise, the term "hazardous waste" also includes extremely hazardous waste and acutely hazardous waste.
10. RECYCLE -- Check the appropriate box to indicate whether you recycle more than 100 kilograms per month of recyclable material under a claim that the material is excluded or exempt per HSC 25143.2. Check []YES[] and complete the Recyclable Materials Report pages, if you either recycled onsite or recycled excluded recyclable materials which were generated offsite. Check []NO[] if you only send recyclable materials to an offsite recycler. You do not need to report.
11. ONSITE HAZARDOUS WASTE TREATMENT -- Check the appropriate box to indicate whether your facility engages in onsite treatment of hazardous waste. "Treatment" means any method, technique, or process which is designed to change the physical, chemical, or biological character or composition of any hazardous waste or any material contained therein, or removes or reduces its harmful properties or characteristics for any purpose. "Treatment" does not include the removal of residues from manufacturing process equipment for the purposes of cleaning that equipment. Amendments (effective 1/1/99) add exemptions from the definition of []treatment[] for certain processes under specific, limited conditions. Refer to HSC 25123.5 (b) for these specific exemptions. Treatment of certain laboratory hazardous wastes do not require authorization. Refer to HSC 25200.3.1 for specific information. Please contact your CUPA to determine if any exemptions apply to your facility. If your facility engages in onsite treatment of hazardous waste then complete the Onsite Hazardous Waste Treatment Notification -- Facility page and one set of Onsite Hazardous Waste Treatment Notification -- Unit pages with waste and treatment process information for each unit.
12. FINANCIAL ASSURANCE -- Check the appropriate box to indicate whether your facility is subject to financial assurance requirements for closure of an onsite treatment unit. Unless they are exempt, Permit by Rule (PBR) and Conditionally Authorized (CA) operations are required to provide financial assurance for closure costs (per 22 CCR. 67450.13 (b) and HSC 25245.4). If your facility is subject to financial assurance requirements or claiming an exemption, then complete the Certification of Financial Assurance page.
13. REMOTE WASTE CONSOLIDATION SITE -- Check the appropriate box to indicate whether your facility consolidates hazardous waste generated at a remote site. Answer []YES[] if you are a hazardous waste generator that collects hazardous waste initially at remote sites and subsequently transports the hazardous waste to a consolidation site you also operate. You must be eligible pursuant to the conditions in HSC 25110.10. If your facility consolidates hazardous waste generated at a remote site, then complete the Remote Waste Consolidation Site Annual Notification page.
14. HAZARDOUS WASTE TANK CLOSURE -- Check the appropriate box to indicate whether the tank being closed would be classified as hazardous waste after its contents are removed. Classification could be based on:
| - Your knowledge of the tank and its contents | - The mixture rule | |
| - Testing of the tank | - The listed wastes in 40 CFR 261.31 or 40 CFR 261.32. | |
| - Inability to remove hazardous materials stored in the tank. |
If the tank being closed would be classified as hazardous waste after its contents are removed, then you must complete the Hazardous Waste Tank Closure Certification page.
14a. RCRA LQG -- Check the appropriate box to indicate whether your facility is a Large Quantity Generator. If YES, you must have or obtain a US EPA ID Number.
14b. HOUSEHOLD HAZARDOUS WASTE COLLECTION -- Check the appropriate box to indicate whether your facility is a HHW Collection site.
15. LOCAL REQUIREMENTS -- Some CUPAs or AAs may require additional information. Check with your CUPA before submitting the UPCF to determine if any supplemental information is required.
UPCF Rev. (12/2007)
Business Owner/Operator Identification
Please submit the Business Activities page, the Business Owner/Operator Identification page, and Hazardous Materials Inventory -- Chemical Description pages for all hazardous materials inventory submissions. For the inventory to be considered complete this page must be signed by the appropriate individual. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form (UPCF) pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3, Electronic Submittal of Information.) Please number all pages of your submittal. This helps Unified Program Agency (UPA) identify whether the submittal is complete and if any pages are separated.
1. FACILITY ID NUMBER -- Leave this blank. This number is assigned by the UPA. This is the unique number which identifies your facility.
3. BUSINESS NAME -- Enter the doing business as name.
100. BEGINNING DATE -- Enter the beginning year and date of the report. (YYYYMMDD)
101. ENDING DATE -- Enter the ending year and date of the report. (YYYYMMDD)
102. BUSINESS PHONE -- Enter the phone number, area code first, and any extension.
102a. BUSINESS FAX -- Enter the business fax number, area code first.
103. BUSINESS SITE ADDRESS -- Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means to geographically locate the facility.
104. BUSINESS SITE CITY -- Enter the city or unincorporated area in which business site is located.
105. ZIP CODE -- Enter the zip code of business site. The extra 4 digit zip may also be added.
106. DUN & BRADSTREET -- If subject to EPCRA, enter the Dun & Bradstreet number for the facility. The Dun & Bradstreet number may be obtained by calling (610) 882-7748 or on the web at www.dnb.com.
107. SIC NUMBER -- Enter the primary Standard Industrial Classification System Number. Required for EPCRA.
107a. NAICS NUMBER -- Enter the primary North American Industrial Classification System Number.
108. COUNTY -- Enter the county in which the business site is located.
108a. BUSINESS MAILING ADDRESS -- Enter the mailing address to be used for all official business correspondence. This mailing address must be filled in.
108b. BUSINESS MAILING CITY -- Enter the name of the city for the business mailing address.
108c. STATE -- Enter the two character abbreviation of the state for the business mailing address.
108d. ZIP CODE -- Enter the zip code for the business mailing address. The extra 4 digit zip may also be added.
109. BUSINESS OPERATOR NAME -- Enter the name of the business operator.
110. BUSINESS OPERATOR PHONE -- Enter business operator phone number, if different from business phone, area code first, and any extension.
111. BUSINESS OWNER NAME -- Enter name of business owner, if different from business operator.
112. BUSINESS OWNER PHONE -- Enter the business owner's phone number if different from business phone, area code first, and any extension.
113. BUSINESS OWNER MAILING ADDRESS -- Enter the owner's mailing address, if different from business mailing address.
114. BUSINESS OWNER CITY -- Enter the name of the city for the owner's mailing address, if different from business mailing address.
115. BUSINESS OWNER STATE -- Enter the 2 character state abbreviation for the owner's mailing address, if different from business mailing address.
116. BUSINESS OWNER ZIP CODE -- Enter the zip code for the owner's address, if different from business mailing address. The extra 4 digit zip may also be added.
117. ENVIRONMENTAL CONTACT NAME -- Enter the name of the person, who receives all environmental correspondence.
118. CONTACT PHONE -- Enter the phone number, if different from Owner or Operator, for the environmental contact, area code first, and any extension.
119. CONTACT MAILING ADDRESS -- Enter the mailing address where all environmental contact correspondence should be sent.
119a CONTACT EMAIL -- Enter the email address of the environmental contact in 117, if the contact has one.
120. CONTACT MAILING CITY -- Enter the name of the city for the environmental contact's mailing address.
121. STATE -- Enter the 2 character state abbreviation for the environmental contact's mailing address.
122. ZIP CODE -- Enter the zip code for the environmental contact's mailing address. The extra 4 digit zip may also be added.
123. PRIMARY EMERGENCY CONTACT NAME -- Enter the name of a representative to be contacted in case there is an emergency involving hazardous materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident mitigation.
124. TITLE -- Enter the title of the primary emergency contact.
125. BUSINESS PHONE -- Enter the business number for the primary emergency contact, area code first, and any extensions.
126. 24-HOUR PHONE -- Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individual stated above.
127. PAGER NUMBER -- Enter the pager number for the primary emergency contact, if available.
128. SECONDARY EMERGENCY CONTACT NAME -- Enter the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident mitigation.
129. TITLE -- Enter the title of the secondary emergency contact.
130. BUSINESS PHONE -- Enter the business telephone number for the secondary emergency contact, area code first, and any extension.
131. 24-HOUR PHONE -- Enter a 24-hour phone number for the secondary emergency contact. The 24 hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individual stated above.
132. PAGER NUMBER -- Enter the pager number for the secondary emergency contact, if available.
133. ADDITIONAL LOCALLY COLLECTED INFORMATION -- This space may be used for UPA to collect any additional information necessary to meet the requirements of their individual programs. Contact UPA for guidance.
134. DATE -- Enter the date that the document was signed. (YYYYMMDD)
135. NAME OF DOCUMENT PREPARER -- Enter the full name of the person who prepared the inventory submittal information.
136. NAME OF SIGNER -- Enter the full printed name of the person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate and complete.
SIGNATURE OF OWNER/ OPERATOR OR DESIGNATED REPRESENTATIVE -- The Business Owner/Operator, or officially designated representative of the Owner/Operator, shall sign in the space provided. This signature certifies that the signer is familiar with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information it is the signer's belief that the submitted information is true, accurate and complete.
137. TITLE OF SIGNER -- Enter the title of the person signing the page.
UPCF Rev. (12/2007)
Hazardous Materials Inventory -- Chemical Description
You must complete a separate Hazardous Materials Inventory -- Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or the federal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantities of hazardous materials at your facility, reported separately for each building or outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form (UPCF) pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3, Electronic Submittal of Information.) Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated.
1. FACILITY ID NUMBER -- This number is assigned by the CUPA or AA. This is the unique number which identifies your facility.
3. BUSINESS NAME -- Enter the full legal name of the business.
200. ADD/DELETE/ REVISE -- Indicate if the material is being added to the inventory, deleted from the inventory, or if the information previously submitted is being revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually.
201. CHEMICAL LOCATION -- Enter the building or outside/ adjacent area where the hazardous material is handled. A chemical that is stored at the same pressure and temperature, in multiple locations within a building, can be reported on a single page. NOTE: This information is not subject to public disclosure pursuant to HSC § 25506.
202. CHEMICAL LOCATION CONFIDENTIAL -- EPCRA -- All businesses which are subject to the Emergency Planning and Community Right to Know Act (EPCRA) must check "Yes" to keep chemical location information confidential. If the business does not wish to keep chemical location information confidential check "No".
203. MAP NUMBER -- If a map is included, enter the number of the map on which the location of the hazardous material is shown.
204. GRID NUMBER -- If grid coordinates are used, enter the grid coordinates of the map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed.
205. CHEMICAL NAME -- Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture, do not complete this field; complete the "COMMON NAME" field instead.
206. TRADE SECRET -- Check "Yes" if the information in this section is declared a trade secret, or "No" if it is not. State requirement: If yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by HSC § 25511. Federal requirement: If yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a "Substantiation to Accompany Claims of Trade Secrecy" form (40 CFR 350.27) to USEPA.
207. COMMON NAME -- Enter the common name or trade name of the hazardous material or mixture containing a hazardous material.
208. EHS -- Check "Yes" if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous components below.
209. CAS # -- Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the appropriate section below.
211. HAZARDOUS MATERIAL TYPE -- Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section.
212. RADIOACTIVE -- Check "Yes" if the hazardous material is radioactive or "No" if it is not.
213. CURIES -- If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies.
214. PHYSICAL STATE -- Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or gas.
215. LARGEST CONTAINER -- Enter the total capacity of the largest container in which the material is stored.
216. FEDERAL HAZARD CATEGORIES -- Check all categories that describe the physical and health hazards associated with the hazardous material.
| PHYSICAL HAZARDS | HEALTH HAZARDS |
| Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Oxidizers | Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, |
| Reactive: Unstable Reactive, Organic Peroxides, Water Reactive, Radioactive | other hazardous chemicals with an adverse effect with short term exposure |
| Pressure Release: Explosives, Compressed Gases, Blasting Agents | Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long term exposure |
217. AVERAGE DAILY AMOUNT -- Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacent/ outside area. Calculations shall be based on the previous year's inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units reported in box 221 and should not exceed that of maximum daily amount.
218. MAXIMUM DAILY AMOUNT -- Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjacent/outside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be consistent with the units reported in box 221.
219. ANNUAL WASTE AMOUNT -- If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled.
220. STATE WASTE CODE -- If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest.
221. UNITS -- Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons).
222. DAYS ON SITE -- List the total number of days during the year that the material Is on site.
223. STORAGE CONTAINER -- Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: If appropriate, you may choose more than one.
224. STORAGE PRESSURE -- Check the one box that best describes the pressure at which the hazardous material is stored.
225. STORAGE TEMPERATURE -- Check the one box that best describes the temperature at which the hazardous material is stored.
226. HAZARDOUS COMPONENTS 1-5 (% BY WEIGHT) -- Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available, report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242.)
227. HAZARDOUS COMPONENTS 1-5 NAME -- When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. (Report for components 2 through 5 in 231, 235, 239, and 243.)
228. HAZARDOUS COMPONENTS 1-5 EHS -- Check "Yes" if the component of the mixture Is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "No" if it is not. (Report for components 2 through 5 in 232, 236, 240, and 244.)
229. HAZARDOUS COMPONENTS 1-5 CAS -- List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. (Repeat for 2-5.)
246. LOCALLY COLLECTED INFORMATION -- This space may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance.
UPCF Rev. (12/2007)
IV. California Annotated Site Map--Instructions
Attach a map of the facility using the standard grid. As a minimum, the map should show the following:
1. Site Layout
* Scale of map
* Site Orientation (north, south, etc.)
* 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
2. Facility
* Location of each storage area
* Location of each hazardous material handling area
* Location of emergency response equipment. For example, equipment for fire suppression, approach and mitigation, protective clothing, medical response, etc.
Cal. Code Regs. Tit. 19, div. 5, ch. 1, art. 3, app B