needed 10

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

HEALTH RISK ASSESSMENT FORM For permit applications that cause emission levels above triggers in Regulation 2, Rule 5

All fields are required unless otherwise noted. Please type or print.

Mail to: BAAQMD

Engineering Division 375 Beale St., Suite 600

San Francisco, CA 94105

Tel: (415) 749-4990

Page 1 of 1  An electronic version of this form and instructions can be found at www.baaqmd.gov.  v10/2017

1. Facility Identification

Facility Name  BAAQMD Facility ID (Existing facilities only)

2. Area Map (See instructions)

I have completed an area map and attached it with this form.    Yes  No 

3. Building Information – Attach separate sheet if additional space is needed.

The dimensions of the buildings listed in this section are in: (Select one)  Feet  Meters  Provide information on all buildings identified in the area map from Part 2. 

Building #  Building Name  Height Width Length  Type of Occupants

4. Device Location – Attach separate sheet if additional space is needed.

Provide information on all devices included in this application. For new devices, skip BAAQMD Device ID.  If device is  outside, skip Building #. 

BAAQMD Device ID  Device Name Location  Building #

5. Certification/Signature of person responsible for the information on this form.

This form contains confidential information.    No  Yes   (If Yes, see instructions.)  I hereby certify that I am authorized to complete this form for the facility and that all information contained herein is true  and correct. 

Name  Title

Signature  Date Phone (xxx‐xxx‐xxxx)

BAY AREA AIR QUALITY MANAGEMENT DISTRICT BAAQMD Engineering Division 375 Beale St., Suite 600 San Francisco, CA 94105

Page 1 of 2 v10/2017

Instructions: Health Risk Assessment (HRA) Form

Introduction Use the following instructions to help guide you through the HRA Form.

BAAQMD evaluates new and modified devices to determine potential public exposure and health risk. Applications with toxic emissions may be required to provide additional information on the HRA Form and an Emission Point Form.

An HRA is an analysis that estimates the increased likelihood of health risk for individuals in the affected population that may be exposed to emissions of one or more toxic air contaminants (TAC). TAC is an air pollutant that may cause or contribute to an increase in mortality or in serious illness or that may pose a present or potential hazard to human health.

Who should use this form?

This form is for:  Permit applications for devices that emit or potentially emit TACs in quantities

over the threshold levels in Table 2‐5‐1 (See BAAQMD Regulation 2‐5). If you are unsure of your application’s emissions, BAAQMD staff will contact you if this form is required.

BAAQMD Facility ID

If you are an existing facility, fill out this field so that BAAQMD can associate your changes to your facility. This Facility ID is available on your Permit to Operate or invoice issued by BAAQMD.

Area Map Provide an area map (aerial photo is recommended) of your facility. The information on the map is used to populate data for the HRA form, so the information must be consistent. The map should:

 Clearly demonstrate the location of your facility, the buildings on the facility property, the device(s), and property lines and can optionally include surrounding buildings off the property.

 Clearly indicate the buildings within 300 feet of each device, facility boundaries, and zoning of the surrounding areas out to 1,500 feet beyond the property line.

 Have numbers for each building on the map.

An example of the area map is attached to the end of these instructions.

Building Information

Provide information on all buildings identified on the area map. Indicate the type of occupants in each building.

 Employees: Facility employees or on‐site workers  Other Workers: Off‐site workers at other businesses.  Residents  Students  Mixed Use: A combination of any of the above occupant types.  No Occupants

BAY AREA AIR QUALITY MANAGEMENT DISTRICT BAAQMD Engineering Division 375 Beale St., Suite 600 San Francisco, CA 94105

Page 2 of 2 v10/2017

Device Location BAAQMD Device ID – The device ID is available on the permit issued by BAAQMD. For Gas Dispensing Facilities, the device ID is a new identifier and will be listed on your Permit to Operate if it was issued after March 5, 2012. Skip if this is not available.

Provide the locations of all devices in the application. Use the same BAAQMD device ID and name as on the device forms (including the Emission Point Form). For the location, choose from the following:

 Inside building  On the roof  Outside building

Still need help? Call the Engineering Division at (415) 749‐4990.

Example Facility Plot Plan:

Frazier Plating, 955 Adams St, Mayberry, CA

Facility Plot Plan Checklist: Your Facility Plot Plan should clearly demonstrate the locations of these items:

Your facility (including address or cross streets)

Buildings on the facility property (please use the same building numbers entered on the online form and Area Map)

Devices (including Emissions Points)

Property lines

Optional: Surrounding buildings off the property

1.

2.

3.

4.

5.

Residential Homes

Industrial

Industrial

Commercial

Fence Line

S-1 Exhaust

B2 (25’Ht)

B1 (25’Ht)

B4

B7

B8

B5

B6

B3

S-1 Exhaust

B2 (25’Ht)

B1 (25’Ht)

Frazier Plating 955 Adams St. Mayberry, CA

250 Ft

Ja ck

so n S

t.

Adam s St.

N

S

W E

BUILDING INFORMATION (Enter information for each building identified on the uploaded map.)

Frazier Painting (shop)

Dimension units displayed in: FEET METERS

BUILDING NUMBER BUILDING NAME HEIGHT WIDTH LENGTH

TYPE OFOCCUPANTS IN BUILDING

Frazier Painting (office)

Ye Old Oak Cooper

7-Eleven

Holiday Inn

Sam’s Barber Shop

Java Quick Stop

Harry’s Automtive

25

25

20

15

35

15

13

22

120

120

90

130

100

45

25

40

80

55

145

55

60

55

30

60

Employees

Employees

Employees

Other Workers

Residents

Other Workers

Other Workers

Other Workers

ADD BUILDING

X

X

Example Facility Area Map:

Facility Area Map Checklist: A Facility Area Map is an aerial image (or series of images) that include the facility property and surrounding area out to 1500 feet beyond the property line in all directions.

Your Area Map should clearly demonstrate the following:

Buildings within 300 feet of each device (please use the same building numbers entered on the online form and Area Map)

Facility boundaries

Zoning of the surrounding areas: • Residential • Commercial • Industrial • Mixed Use (please specify)

1.

2.

3.

S1 Exhaust

Fence Line

B4

B3

B8

B2

B1

B6

B5

N

S

W E

Commercial

W as

hin gt

on S

t.

Ja ck

so n

St .

A dam

s St.

Commercial

Industrial

N

S

W E Residential

Homes

Mixed Use

S1

Fence Line

B4

B3

B8

B2 B1 B6

W as

hin gt

on S

t. Ja

ck so

n St

.

A dam

s St.

B5

B7

B ryant St.

B rannan St.

Pa rk

er S

t.

Dr um

m S

t.

Cl ay

S t.El

lis S

t.

Va lle

jo S

t.

Example Zoning Map:

X

X

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

HEALTH RISK FORM For permit applications that cause emission levels above triggers in Regulation 2, Rule 5 All fields are required unless otherwise noted. Please type or print.

Mail to:

Tel:

Page 1 of 1 An electronic version of this form and instructions can be found at www.baaqmd.gov. v /201

1. Facility Identification

Facility Name BAAQMD Facility ID (Existing facilities only)

2. Area Map (See instructions)

I have completed an area map and attached it with this form. Yes No

3. Building Information – Attach separate sheet if additional space is needed.

The dimensions of the buildings listed in this section are in: (Select one) Feet Meters Provide information on all buildings identified in the area map from Part 2.

Building # Building Name Height Width Length Type of Occupants

4. Device Location – Attach separate sheet if additional space is needed.

Provide information on all devices included in this application. For new devices, skip BAAQMD Device ID. If device is outside, skip Building #.

BAAQMD Device ID Device Name Location Building #

5. Certification/Signature of person responsible for the information on this form.

This form contains confidential information. No Yes (If Yes, see instructions.) I hereby certify that I am authorized to complete this form for the facility and that all information contained herein is true and correct.

Name Title

Signature Date Phone (xxx xxx xxxx)

Frazier Plating 12345

1 Frazier Painting (Shop) 25 120 80 Employees

2 Frazier Painting (Office) 25 120 55 Employees

3 Frazier Warehouse 20 90 145 Employees

4 The 24/7 Store 15 130 55 Other Workers

5 The Holiday Hotel 35 100 60 Residents

6 Sam's Barber Shop 15 45 55 Other Workers

7 The Coffee Shop 13 25 30 Other Workers

8 Jane's Automotive Shop 22 40 60 Other Workers

S-1 Metal Coating Operation Southwest Corder of Building B-1

Jane Doe Compliance Manager

5/4/2016 415-555-1234

1. Facility NameRow1:
2. BAAQMD Facility ID Existing facilities onlyRow1:
3. Building Row1:
4. Building NameRow1:
5. HeightRow1:
6. WidthRow1:
7. LengthRow1:
8. Building Row2:
9. Building NameRow2:
10. HeightRow2:
11. WidthRow2:
12. LengthRow2:
13. Building Row3:
14. Building NameRow3:
15. HeightRow3:
16. WidthRow3:
17. LengthRow3:
18. Building Row4:
19. Building NameRow4:
20. HeightRow4:
21. WidthRow4:
22. LengthRow4:
23. Building Row5:
24. Building NameRow5:
25. HeightRow5:
26. WidthRow5:
27. LengthRow5:
28. Building Row6:
29. Building NameRow6:
30. HeightRow6:
31. WidthRow6:
32. LengthRow6:
33. Building Row7:
34. Building NameRow7:
35. HeightRow7:
36. WidthRow7:
37. LengthRow7:
38. Building Row8:
39. Building NameRow8:
40. HeightRow8:
41. WidthRow8:
42. LengthRow8:
43. Building Row9:
44. Building NameRow9:
45. HeightRow9:
46. WidthRow9:
47. LengthRow9:
48. Building Row10:
49. Building NameRow10:
50. HeightRow10:
51. WidthRow10:
52. LengthRow10:
53. BAAQMD Device IDRow1:
54. Device NameRow1:
55. LocationRow1:
56. Building Row1_2:
57. BAAQMD Device IDRow2:
58. Device NameRow2:
59. LocationRow2:
60. Building Row2_2:
61. BAAQMD Device IDRow3:
62. Device NameRow3:
63. LocationRow3:
64. Building Row3_2:
65. BAAQMD Device IDRow4:
66. Device NameRow4:
67. LocationRow4:
68. Building Row4_2:
69. BAAQMD Device IDRow5:
70. Device NameRow5:
71. LocationRow5:
72. Building Row5_2:
73. BAAQMD Device IDRow6:
74. Device NameRow6:
75. LocationRow6:
76. Building Row6_2:
77. BAAQMD Device IDRow7:
78. Device NameRow7:
79. LocationRow7:
80. Building Row7_2:
81. BAAQMD Device IDRow8:
82. Device NameRow8:
83. LocationRow8:
84. Building Row8_2:
85. BAAQMD Device IDRow9:
86. Device NameRow9:
87. LocationRow9:
88. Building Row9_2:
89. BAAQMD Device IDRow10:
90. Device NameRow10:
91. LocationRow10:
92. Building Row10_2:
93. NameRow1:
94. TitleRow1:
95. DateRow1:
96. Phone xxxxxxxxxxRow1:
97. Area map: Off
98. Building units: Off
99. Confidential: Off
100. Type of OccupantsRow1: [ ]
101. Type of OccupantsRow2: [ ]
102. Type of OccupantsRow3: [ ]
103. Type of OccupantsRow4: [ ]
104. Type of OccupantsRow5: [ ]
105. Type of OccupantsRow6: [ ]
106. Type of OccupantsRow7: [ ]
107. Type of OccupantsRow8: [ ]
108. Type of OccupantsRow9: [ ]
109. Type of OccupantsRow10: [ ]