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Attachment J ATRUE COPY <br />CERTIFICATION ON LAST PAGE <br />2021-2022 Hazard Analysis Checklist �.R. SMITH, CLERK <br />(All HA's must include the following items at minimum.) <br />on on on main Facility Field.) (file name must contain at minimum the SERC acronym SP — if <br />SERC number and date. (additional info encouraged but not reauired.l <br />Sufficient Detail to Identify: North Arrow <br />Location of Major Buildings <br />Name and Location of Extremely Hazardous Substance( <br />Name and Location of Street( <br />Identify Pertinent Access and <br />Hazardous Substances are <br />'list the street the facility is on and at a minimum one cross <br />!ss Points and other features pertinent to Emereencv Remi <br />30 <br />EHS is <br />2021-22 Hazards Analysis Grant Attachment JHA Checklist 10/7/2021 <br />Facility Field Information <br />Facility Name (per current facility list } <br />Department field is where the SERC number goes. fDo not add the SERC acronym just the number} <br />Enter the current Tier II report year <br />Facility Physical Address <br />Latitude and Longitude in Decimal Degrees (ex. 30.197, -84.36211 <br />Facility Phone Number <br />Facility Emergency Coordinator Name, Title, and 24-hour Emergency Phone Number <br />Transportation Route(s) (From County Line to the Facility} <br />Evacuation Route(s) to exit the Vulnerable Zone <br />Historical Accident Record fIf none, please note} <br />Facility Maximum Occupancy {a minimum of one is required for unmanned facilities} <br />Facility Page (ID and Regs ) (Mark correct 112(r) and Section 302 check boxes, max occupancy, facility manned or unmanned) <br />Hazard Identification (Chemical in Inventory Field Section) (for each Extremely Hazardous Substance on site) <br />Update Chemical in Inventory section for each Extremely Hazardous Substance Present over the TPQ <br />Enter Chemical Abstract Service (CAS) Number and Proper Chemical Name <br />Type/Design, Pressure, and Temperature of Container(s) cylinder, battery, ambient etc. (Chemical in Inventory Location field) <br />Physical State in Storage (ex. mixture, pure, liquid, gas} (Chemical in Inventory Physical State and Quantity field) <br />Enter max daily, average daily amount in lbs. (Chemical in Inventory Physical State and Quantity field) <br />Enter amount in Largest Container or Interconnected Containers (Chemical in Inventory Physical State and Quantity field) (this is the <br />amount to be used in the scenario release} <br />Nature of the Hazard - Physical and Health check boxes fex. acute, chronic, fire, pressure, etc.} (Chemical in Inventory field) <br />Vulnerability <br />Analysis (Scenario Fields accessible from each individual EHS Chemical) <br />Enter maximum amount in largest container or interconnected containers in the Amount Released field (Scenario ) (This amount <br />must be the same as the Chemical in Inventory field Maximum amount in largest container amount) <br />Enter the concentration percentage in the Concentration field (Scenario Description field) <br />Enter Release Duration (10 minutes for gases, solids in solution or powders; no entry for liquids is required) (Scenario Description field) <br />Determine the natural Physical State of each chemical (If you don't know it's often specified in Cameo Chemicals add on module) and <br />enter it into the Scenario Physical description field.) <br />Weather Information - Use the weather default settings or enter average wind speed (do not enter a value in the Wind from field) <br />Urban or Forest is recommended in the Ground Roughness field. <br />(Scenario Description field.) <br />Risk Assessment - Rate the Risk, Consequences and Overall Risk of a release occurring (based upon release history etc.) (Scenario <br />Description field) <br />Extent of Vulnerable Zone (CAMEO automatically calculates Threat Zone Radius when Edit button and Estimate Threat Zone Radius <br />buttons are used) (Scenario Description field) <br />Enter estimate of Total Exposed Population (Notes area in Scenario) <br />Enter Critical Facilities f name of critical facility(s) and max occupancy for each; if none, state No Critical Facilities) (Notes area in Scenario) <br />On -Site Visits, Statements of Determination, and Site Plans (For each Facility within Agreement Period of Performance.) <br />Site Visit Certification Form (Upload to attachment section on main Facility Field.)( file name must contain at minimum the SERC <br />number, SV and date. Phone call updates must indicate who made the <br />call, the name of the facility representative spoken to, and <br />the date of call.) <br />Statement of Determination (SOD) if applicable (Upload to Attachment Section on main Facility Field) {file name must contain at <br />minimum SERC number and proper acronym SOD and date. <br />Site Plan (SP) (Upload to Attachment Sea; <br />on on on main Facility Field.) (file name must contain at minimum the SERC acronym SP — if <br />SERC number and date. (additional info encouraged but not reauired.l <br />Sufficient Detail to Identify: North Arrow <br />Location of Major Buildings <br />Name and Location of Extremely Hazardous Substance( <br />Name and Location of Street( <br />Identify Pertinent Access and <br />Hazardous Substances are <br />'list the street the facility is on and at a minimum one cross <br />!ss Points and other features pertinent to Emereencv Remi <br />30 <br />EHS is <br />2021-22 Hazards Analysis Grant Attachment JHA Checklist 10/7/2021 <br />