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City of Anaheim Certified Unified Program Agency REGULATED SUBSTANCE REPORTING FORM California Accidental Release Prevention Program 201 S. Anaheim Blvd., Anaheim, CA 92805 (714) 765-4040 White – Fire Department Yellow - Business Rev: 7/1/01 This form is to be completed by each facility that has a Regulated Substance (RS) above the Threshold Quantity in a Process (see instructions on reverse page). This information is required for compliance with the California Accidental Release Prevention (Cal-ARP) program found in Chapter 6.95, California Health and Safety Code (H&SC). A separate form shall be submitted for each Regulated Substance in each Process. 1. BUSINESS NAME: 2. ADDRESS: 3. CONTACT NAME: 4. CONTACT TITLE: 5. PHONE 6. PROCESS SIC: 7. IS FACILITY SUBJECT TO 29 CFR §1910.119 (OSHA PSM)? YES NO 8. IS THE REGULATED SUBSTANCE LISTED IN 40 CFR §335, APPENDIX A (EHS)? YES NO 9. IS PROCESS SUBJECT TO CAA TITLE V OPERATING PERMIT? YES PERMIT # NO 10. CHEMICAL NAME: 1. CAS 12. PERCENT: 13. QUANTITY IN PROCESS (LBS): PHYSICAL STATE: SOLID LIQUID GAS 14. PROCESS DESCRIPTION: 15. PROCESS EQUIPMENT: CERTIFICATION I, the owner or operator of the aforementioned business, hereby certify that the information provided is true, accurate, and complete to the best of my knowledge based upon reasonable inquiry. I am fully aware that this certification, executed on the date indicated below, is made under penalty of perjury under the laws of the State of California. 16. OWNER/OPERATOR NAME: 17. OWNER/OPERATOR TITLE: OWNER/OPERATOR SIGNATURE: 18. DATE EXECUTED: ---PAGE BREAK--- City of Anaheim Certified Unified Program Agency REGULATED SUBSTANCE REPORTING FORM California Accidental Release Prevention Program 201 S. Anaheim Blvd., Anaheim, CA 92805 (714) 765-4040 White – Fire Department Yellow - Business DEFINITIONS Cal-ARP is the California Accidental Release Prevention program pursuant to Article 2, Chapter 6.95 H&SC. RMP is a Risk Management Plan developed by a business to prevent the accidental release of Regulated Substances from a facility, which could adversely affect public health and/or the environment. REGULATED SUBSTANCE (RS) is any substance listed pursuant to §68.130, 40 CFR and/or §2770.5, Title 19 California Code of Regulations (CCR), (Tables 1, 2 & THRESHOLD QUANTITY means the quantity specified for an RS pursuant to §68.130, 40 CFR and §2770.5, Title 19 CCR and determined to be present at a stationary source as specified in §68.115, 40 CFR and §2770.2, T19 CCR. PROCESS means any activity involving a regulated substance including any use, storage, manufacturing, handling, or onsite movement of such substances, or combinations of these activities. For the purpose of this definition, any group of vessels that are interconnected, or separate vessels that are located such that a regulated substance could be involved in a potential release, shall be considered a single process. STATIONARY SOURCE means any buildings, structures, equipment, installations, or substance emitting stationary activities which belong to the same industrial group, which are located on one or more contiguous properties, which are under the control of the same person, and from which an accidental release may occur. A stationary source includes transportation containers that are no longer under active shipping papers and transportation containers that are connected to equipment at the stationary source for the purposes of temporary storage, loading, or unloading. KEY 1. BUSINESS NAME: Enter the full legal name of the business/stationary source. 2. ADDRESS: Postal standard address where the facility/process is located. 3. CONTACT NAME: The designated person responsible for developing the Risk Management Plan. 4. CONTACT TITLE: Title of responsible person. 5. PHONE Responsible persons' phone number. 6. PROCESS SIC: Standard Industrial Classification code number for the process handling the RS. 7. OSHA PSM: Is the process subject to the OSHA Process Safety Management standards pursuant to 29 CFR §1910.119 (or California equivalent pursuant to Title 8 CCR §5189)? Contact Cal- OHSA Consultation Services @ (562) 944-9366 for more information on PSM requirements and applicability. 8. EPCRA SECTION 302: The Emergency Planning and Community Right-to-Know Act (40 CFR §302) requires notification to local agencies of the presence of Extremely Hazardous Substances (EHS) above a threshold as listed in 40 CFR §355, Appendix A. Call the EPCRA Hotline @ 1-[PHONE REDACTED] for more information. 9. CAA TITLE V: Processes subject to Clean Air Act, Title V requirements must have an operating permit issued through the SCAQMD and certify compliance with the RMP, if applicable. Include Permit number. Call 1-800-CUT-SMOG for more information on Title V Permits. 10. CHEMICAL NAME: The proper chemical name of the material being reported or the common/trade name if it is a mixture. 11. CAS The Chemical Abstract Service number for the RS being reported. If the process contains more than one regulated substance, report each on a separate form for that process. 12. PERCENT: The percentage by weight of the regulated substance in a mixture. If the RS is not in a mixture write N/A. 13. QUANTITY IN PROCESS: The maximum amount of the RS in the process at any one time. All materials must be reported in pounds. If there is more than one RS or Process each must be reported separately. 14. PROCESS DESCRIPTION: Describe the Process and/or operations that involve the use, storage, generation, production or handling of the RS. Include process temperatures and pressures if applicable. 15. PROCESS EQUIPMENT: List the principal equipment and/or components used in the process. 16. OWNER/OPERATOR NAME: The full name of the business owner/operator (or corporate officer) who will be signing the registration form and certification. 17. TITLE: The full title of the person signing the registration form and certification. 18. DATE EXECUTED: Enter the date form was signed. Rev: 7/1/01