Hazardous Materials Business Plan And Inventory Certification Form - Riverside Country Department Of Environmental Health
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Riverside County Department of Environmental Health
Level________________
Hazardous Materials Management Branch
Initials_______________
HAZARDOUS MATERIALS BUSINESS PLAN AND INVENTORY CERTIFICATION FORM
Date Reviewed________
This form must be submitted annually as required by the California Health & Safety Code (H&SC) Section 25505 (c) & (d), and Section
25270.6 (a)(1). Failure to do so may result in civil and criminal penalties. Notification should be made to this agency within 30 days if
any of the following events occur: change of ownership; change of business name; mailing address; phone number; location; emergency
contact person; 100% or more increase in the quantity of a disclosed material; or any handling of a previously undisclosed material
subject to regulation. A copy of this form should be kept at the business and available for review upon request of this department. This
form can only be used if you have already submitted the most current version of the Hazardous Materials Business Plan and Inventory
Forms. If your business is regulated under the Aboveground Petroleum Storage Act (APSA), this form meets the annual reporting
requirements. However, if your business is regulated under the Emergency Planning and Community Right-to-Know Act (EPCRA), this
form does not meet the annual inventory reporting requirements.
Business Name _____________________________________________________________ Facility # FA00______________________
Owner/Operator Name ______________________________________________________ Telephone _________________________
Facility Address _______________________________________________________________________________________________
City ____________________________________________________
State ___________ Zip Code _________________________
SECTION 1 MUST BE COMPLETED ANNUALLY:
Annual Hazardous Materials Business Plan Inventory Review and Update (Check one box only)
The information contained on the annual inventory form most recently submitted to the administering agency is complete,
accurate, and up to date and complies with all of the following statements:
1. There has been no change in the quantity of any hazardous material as reported in the most recently submitted annual
inventory;
2. No hazardous materials subject to the inventory requirements of Chapter 6.95 H&SC are being handled that are not
listed on the most recently submitted annual inventory form; and
3. The most recently submitted annual inventory form contains the information required by sec. 11022 of Title 42 of the
United States Code. (The Hazardous Materials Inventory – Chemical Description form meets this requirement)
The hazardous materials inventory as previously reported has changed. Attached are new inventory reporting forms for all
changes.
I certify under penalty of law that I have examined and am familiar with the information submitted in this and all attached
documents, that the information provided herein is true, accurate, and complete to the best of my knowledge.
Name ________________________________________________ Signature ______________________________________________
Title _________________________________________________ Date __________________________________________________
Business Name _____________________________________________________________ Facility # FA00______________________
Owner/Operator Name ______________________________________________________ Telephone _________________________
Facility Address _______________________________________________________________________________________________
City ____________________________________________________
State ___________ Zip Code _________________________
SECTION 2 MUST BE COMPLETED ONCE EVERY 3 YEARS:
Triennial (3 Year) Hazardous Materials Business Plan Review and Certification (Check one box only)
I certify that the Business Plan has been reviewed and the information contained in it is accurate and complete. My Business
Plan was last certified on this date ________________
.
I certify that I have reviewed the Business Plan and have updated the following items (updated items are attached):
___ Emergency contacts names and/or telephone numbers
___ Site and/or facility map(s)
___ Emergency response plans and procedures and/or training
___ Training plan
___ Other Information: _____________________________________________
I certify under penalty of law that I have examined and am familiar with the information submitted in this and all attached
documents, that the information provided herein is true, accurate, and complete to the best of my knowledge.
Name _________________________________________________ Signature _____________________________________________
Title __________________________________________________ Date __________________________________________________
INSTRUCTIONS
KEEP A COPY OF THIS CERTIFICATION FORM WITH YOUR HAZARDOUS MATERIALS BUSINESS PLAN RECORDS
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