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' San Joaquin County Environmental Health Department HAZARDOUS MATERIALS PROGRAM TFis survey form Is Inlentlad [o itlentify businesses which need to comply wiN the hazardous materials emergency planning and reporting requirements of iha California Health and Safety Coda (HSC)Chapter 6.95. This Chapter requires bustnessas which handle hazardous materials[o prepare amargenry plans for their employees to use In an emergency. Bualnesaas mus[ submit a copy of tMs plan. along with a ual Inventory of Nair hazardous matartels, [o public safety agendas for u a in protecting emergency responders and [ha general public. In San Joaquin County, the Environmental Health Department (EHD)has been authorized to administer Nla program as the Certified Unified Progrem Agency or CUPA. Should you have any questions about[M1e CUPA program or this form,please tooted:EHD at(209)468-3420. Please wnsider the following guidelines when completing[he questions on page 1: Question 1- Tha (HSC) section 25601(p) datings a "Hazartlous Ma[adal" a any material Nat, because of its quantity, c antregon, o phyatcal o chemical charadarts[ics. poses a significant present or potential hazard to human healfF and safety or to iha nvlronmant If released into the workplace or iha environment. "Hazardous Materials" include but a not limited to, hazardous substances, hazardous waste.and any matadal thaS a handler or Na adminlatadnfl agency Fas a reasonable basis for believing that it would be injurious W the M1eatth and safety of parsons or harmful to the environment If released info [ha orkplace pr the a en[. TFis includes, but is no[ Ilmi[atl to, fuels, petroleum protluds. paints, propane, oxygen, onia, chlorine, pesticides. fertilizers, and used oil. If a buslnass generates a unt oT hazardous safe Nay must enroll in[he EHD Hazardous Was[a Ganeretor Program, Answer"Yes"If you use a mater al Nat meets the deflnldon above In any quantity at least once in Na year. IT you ere unsure, contact[he EHD at(209)46H-3420 Tor assistance. If you answer "No"and at a later data your buslnass,or a tenant on your property,bagina handling hazardous materials,you must inform the EHD within 30 days. Quasgon 2: If you answer "Yes", you must meat the requiremanW of HSC Chapter 6.96. Tha EHD will ba contacting you to provide essls[ance. Thane requirements must ba mat prior to Issuance o(a certificate of occupancy. If you answer"No". our oftica may contlud an Inspection after you begin operegons io verify your exemption. The HSC astablishas a modified requirements or proflrem exemptions for certain u of hazardous materials. If you ensweretl Was" [o quea[lons 1 and 2, a tlatarmination must be matle If your buslnass meats o of thea mption¢ listed. Check the appropriate boxes on page 1. Tha EHD will contact you tp make a final tle[arminatlon if your buslnass meets the exemptions. A. Retail Examotlon-Products packaged for direct diaMbution to[he general public are exempt from Ne program. Thi¢exemption may no[apply If any of the following conditions exist: 1.Tha quantity handled create¢en unacceptable public hazard 2. Tha matadal la being used tliretay by the busine¢s es pert of Its operation In addition [o being gold to iha general public 3. Tha general public tloean't have ready access [o the product as stored by [ha buslnass (a.g. in a warehouse). B. Modified Farm Examo6on - Farms, as stated In Quaation 26 on pafla 1, mus[ mea[ moemaa p pulrements. Tha definition of a farm in the law doesn't include businesses providing w martial past control service¢, fertilizer applica[lon s rvicas, product processing services, or packing shad a rvicas for (armors. Forma qualifying for thea mption are¢till required to submit an a ual chemical Inventory end fee to the San Joaquin County Office of Na Agricultural Commiasionar(OAC) along with other requirements_ Please contact the OAC for further Information a[(209)953-6000_ Businesses operating a commercial busina¢s In atltll[lon[o a fano es tleflnad must comply with the requiramanb of Ne Hazardous Materials Program for those materials associated with the commerolal buslnass. Question 3: Tha Fetlaral and State govammenta have defined approximately 366 chemicals as a "Acutely Hazardous Matadal" (AHM). The most c mon AHM used in Ne c unly include: Chlorine, Ammonia. Sulfuric Acid, Methyl Bromide, Acrolain, Sulfur Dioxide,Fonnaldehyda,NI[ric Acld.Vinyl Acetate Monomer,Hydrogen Paroxitle,end many types of Pasticltlas. Answer"Yes"if you u any of IM1esa specific chemicals in any quantity at any one time oT Na yeas Contac[the EHD If you're unsure for assistancaSe Quasdon 4: Answer"Yes"if the boundary of your property or facility is or will ba within '1,000 feat of the boundary oT a school.(or.ea.K-ta) 2