EPCRA

EMERGENCY RESPONSE PLAN QUESTIONNAIRE

This document, when properly completed, meets the requirements of Arizona Revised Statutes 26-347. It will be reviewed annually by the facility coordinator. The capability to execute the plan on the request of the Arizona Emergency Response Commission or the Local Emergency Planning Committee can be demonstrated. In preparing this plan, the coordinator has consulted with the local emergency planning committee and other emergency and health professionals to assure maximum coordination with those whose cooperation or services may be required in the event of a reportable release.

Facility/Site Name

STATEMENT OF CERTIFICATION

I certify that the information provided herein is accurate and complete as possible

Name Facility Representative (Print)

Title Facility Representative (Print)

Facility Representative’s Signature

Date Signed

UPON COMPLETION OF THIS QUESTIONNAIRE, SEND A COPY TO THE FOLLOWING AGENCIES:

1. Arizona Emergency Response Commission

2. Local Emergency Planning Committee

3. Fire Department/District with Jurisdiction

EPCRA

EMERGENCY RESPONSE PLAN QUESTIONNAIRE

NOTE: Changes in this revision are bolded and italicized. See Questions 11, 12, 13, 19 and 20.

1. Facility Information:

Name:

Street Address:

City: State: Zip Code:

Note: If street address is not available enter physical location, e.g., 1/4 mile south of Smith Highway on Jones Road.

2. Facility o is o is not on Indian land.

Name and Address of Indian Nation, if applicable:

3. Facility Emergency Coordinator:

1. Name:

B. Title/Position:

C. Telephone: Business 24 Hour

4. Alternate Facility Emergency Coordinator:

A. Name:

B. Title/Position:

C. Telephone: Business 24 Hour

5. Fire Department/District having jurisdiction (Note: Please confirm before entering).

6. Provide a brief description of the product(s) or service(s) provided at this facility. Include how extremely hazardous substances are used (e.g., Jones Gear, Inc. is a fabricator of precise machined metal components for the aerospace industry. Extremely hazardous substances stored on-site are used to treat the surface of metal as it is turned into a final product.)

7. Days of the week in operation (e.g. Monday through Friday).

8. Hours of operation (e.g. 8:00 a.m. to 5:00 p.m.).

9. Number of personnel for (include office staff and other support personnel during each shift).

Day Shift

Swing Shift

Night Shift

10. Hazardous materials clean up and disposal assistance (check one and complete specified information when applicable).

o No pre-arrangements made

o Pre-arrangements made with

Company Name:

Telephone Number

Address

11. Briefly specify the in-house emergency response procedures to be used in the event of an imminent or accidental reportable release of an extremely hazardous substance (EHS), to safeguard the public health, safety, welfare and the environment to the maximum extent practicable.

Include:

A. On-site response capabilities and levels of training commensurate with 29 CFR 1910.120, as applicable, to include personnel involved and actions to be taken.

B. Identification of emergency units on or in close proximity to the facility to include fire, emergency medical and law enforcement.

C. Planned notification procedures: on-site personnel and response agencies and off site-site response and regulatory agencies. Address both on-site/off-site alarms, sirens/horns etc., for personnel notification, and procedures for providing reliable, effective, and timely notification by the facility emergency coordinator to the public that a release has occurred.

D. Evacuation plans to include routes, assembly areas and personnel accounting procedures.

12. Briefly describe methods the facility will use to determine 1) the occurrence of a release, and 2) the area likely to be affected during a release of an EHS (e.g., computer modeling, chemical detection equipment, emergency personnel surveillance, etc). Include methods used both on/off-site, as applicable.

13. Identify general transportation routes and methods to transport extremely hazardous substances to/from the facility, if known. This information will assist in the overall hazard analysis program. Identification of routes on the site map requested in question #20 would be helpful, along with alternative emergency traffic routes to be used in the event of an evacuation or for emergency response access.

14. Describe technical expertise (e.g., chemist, engineer, industrial hygienist, etc.) you would make available to public agencies in the event of an EHS release from your facility.

List titles and the type of expertise (names/ phone numbers are not required).

o If not applicable, check here.

Note: This information will assist local emergency agencies. Contact, if required, will be through the Facility Emergency Coordinator.

15. Indicate all internal electronic communications systems to be used by facility personnel in an emergency situation.

Phone: Intercom:

Two-way Radio:

Frequencies: Primary Alternate

Other: (Specify)

16. Please specify the general property use of sites contiguous to your facility.

For purposes of this questionnaire, the term "contiguous" means "directly adjacent to and within approximately one-quarter mile of the property line in the indicated direction." It is likely that along one property line there may be multiple uses of the land. Please list all major uses of the land within the definition (i.e., mixed residential/commercial or residential/light industry or apartments/residential or vacant land/residential, etc.).

North

South

East

West

17. Indicate the type of operations involving EHS(s). Check all applicable categories.

o Hydraulic Equipment o Dust Collectors o Drying Rooms

o Pickling or Garnetting o Electro Plating o Flow Coaters

o Magnesium Processing o Spray Painting o Dip Tanks

o Molten Salt Baths o Ovens, Process o Baler or Shredder

o Fiberglass Operations o Welding/Cutting o Dry Cleaning

o Above Ground Tanks o Under Ground Tanks o Cryogenic Gas

o Compressed Gas o Liquified Gas o Laboratory Chemical

o Combustible Metal Processing

Other

18. List fixed and/or portable chemical detection equipment (if any) available for monitoring releases of extremely hazardous substances e.g., combustible gas analyzers, oxygen meters and fixed monitoring systems.

ITEM GENERAL USE FIXED OR PORTABLE

19. List facility emergency equipment and supplies for use in the event of an unplanned release of EHS, and an identification of persons responsible for such equipment and facilities. Use the format shown below:

Note: Include spill kits, self-contained breathing apparatus (SCBA), absorbent pillows, fire fighting equipment, foam, etc.

TYPICAL QUANTITY

ITEM GENERAL USE ON HAND

e.g. absorbent pillows solvent spills 5-20 lb bags; 1 case

20. Provide a legible site map (8-1/2" X 11") of your facility showing locations of building, general area of storage, EHS storage locations, general description of routes used for deliveries of EHS to/from the facility, and roadway entrances to include street names. Large facilities on multiple sites or multiple areas may choose to use more than one map to show all applicable information requested.

HAZARD ANALYSIS WORKSHEET

Instructions: Complete a hazard analysis worksheet for each Extremely Hazardous Substance on-site at any one time at or above the threshold planning quantity.

1. Chemical Name

2. Chemical Abstract Service (CAS) Number

3. Anticipated chemical physical property during:

Normal Use: o Solid o Liquid o Gas

Unplanned Release: o Solid o Liquid o Gas

4. If the extremely hazardous substance is a component in the mixture enter the weight percentage or the range of weight percentages for multiple mixtures of the EHS (e.g., 10% arsenic or 2-98% sulfuric acid)

Mixture Percentage (if applicable)

5. Is the temperature of the liquid above ambient temperature o Yes o No or near boiling temperature o Yes o No, if the extremely hazardous substance is stored as a liquid?

In general what is the temperature of the EHS?

6. Is there a dike under the container of liquid or molten solid? o Yes o No

If so, what is the area, in square feet, of the diked area?

7. List the largest amount of EHS in a single container or vessel or group of interconnected vessels.

Pounds

Note: List only the actual weight of the extremely hazardous substance in the single largest container or interconnected group of containers at your facility. Keep in mind that for mixtures or solutions use only the weight of the actual EHS. If the EHS is a liquid or gas, conversion data to pounds may be found on the material safety data sheet (MSDS) for the EHS or by contacting the vendor.

8. Identify additional engineering controls, safeguards and/or actions taken by the facility which could decrease the risk associated with the worst case scenario involving this EHS (e.g., written procedures, alarm systems, building/fire code compliance, etc.).