HMD Forms - County Of San Diego

Starting January 1, 2013 all Certified Unified Program Agency (CUPA) regulated businesses are required by law (Assembly Bill 2286) to submit business information electronically through the California Environmental Reporting System (CERS). This includes information related to your:

• Unified Program Facility Permit (UPFP)
• Hazardous Materials Business Plan (HMBP)
• Hazardous Waste
• Hazardous Waste Onsite Treatment
• Hazardous Waste Tank Closures
• Remote Waste Consolidation
• Recyclable Materials Reports
• Underground Storage Tanks (UST)
• Aboveground petroleum storage (APSA) over 1,320 gallons

Many of the forms previously available through the Hazardous Materials Division (HMD) are now required to be completed and/or uploaded in CERS. The form list is now organized by subject and submission requirement. Locate the form you need to complete and refer to the subheading for submittal directions.  

All forms required to be submitted to HMD should sent to:                                                                                       Hazardous Materials Division                                                                                                                                    P.O. Box 129261                                                                                                                                                          San Diego, CA 92131

Ask your Specialist for the best FAX number or e-mail address to use. If you do not know who your Specialist is, contact the HMD Duty Desk at (858) 505-6880.

***PLEASE BE ADVISED***

A copy of all completed forms should be kept onsite for inspection review.

For more details on completing CERS, please refer to our CERS Information Page.

 

General Business Forms for All Facilities

Complete in CERS in the Facility Information section:

Business Activities

Business Owner/Operator Identification (Certification Statement is included)

Complete form and send to HMD (mail, email or fax):

CERS Application Form (English) HMF-1000 (Replaces old CERS Access Form)                                                  CERS Application Form (Spanish) HMF-1000  NEW!

Corrective Action Form to Document Return to Compliance HM-926

Hazardous Materials Questionnaire  (Please utilize the Online Hazardous Materials                                          Questionnaire during this time)

Tenant improvement and new business forms and information

 

Hazardous Materials Forms including Business Plan

Hazardous Materials Business Plan (HMBP) Instructions and Templates HM-952

Complete in CERS in the Hazardous Materials Inventory section

Hazardous Materials Inventory - Chemical Description

Complete form and upload in CERS in the Hazardous Materials Inventory section:

Sitemap Multi-page site maps should be uploaded as a single document (Microsoft Word Version)

Disclosure of Hazardous Materials Information Bulletin HM-9243

(HM-9243 includes Carcinogen & Reproductive Toxin Report and Highly Toxic Gases)

Remote Site Notification Form HM-9283

Property Owner Notification Form

Complete form and upload in CERS in the Emergency Response and Training Plans sections:

Consolidated Emergency Response/Contingency Plan

More information about the Hazardous Materials Business Plan

CalARP Forms

Complete form and send to HMD (mail, email or fax):

CalARP Screening, Disclaimer and Deregistraion Guide HM-9220

CalARP Screening, Disclaimer and Deregistration Form HM-9221

How to Determine TQs & TPQs HM-9181

CalARP Screening Worksheet HM-9223

Risk Management Plan (RMP) Registration/ Work Plan HM-9240

For more information, go to the HMD’s CalARP Program page. For CalARP-related guidance documents, go to the HMD’s Publications and Guidance Documents page.

Hazardous Waste Forms

Non-RCRA and/or RCRA-Exempt Hazardous Waste Storage Extension Notification Form -  HMD is accepting electronic submittals of this notification in addition to your certified mail (with return receipt) request.

Remote Waste Consolidation Site Annual Notification Form HM-9714

Complete form and upload in CERS in the Hazardous Waste Tank Closure Certification section:

Hazardous Waste Tank Closure Certificate           Hazardous Waste Tank Closure Notification

Complete form and upload in CERS in the Recyclable Materials Report Documentation section:

Recyclable Materials Report

Complete form and send to HMD (mail, email or fax):

Aerosol Can Processing - Notification HM-9284

AST Certification & Engineering Assessment Exemption - Notification HM-9271

Complete form and upload in CERS in the Emergency Response and Training Plans section” as “Miscellaneous State-Required Documents”:

Quick Reference Guide - QRG

If opting to use these forms for documentation requirements, complete them and keep onsite for inspection review:

Hazardous Waste Tank System Daily Inspection Log HM-9321

Arrangements with Local Authorities HMF-3023

More information about Hazardous Waste and additional Hazardous Waste Guidance Documents

 

Onsite Hazardous Waste Treatment - Tiered Permitting Forms

Complete in CERS in the Tiered Permitting section:

Hazardous Waste Treatment Notification-Facility Page

Hazardous Waste Treatment Notification-Unit Page

- Conditionally Authorized

- Conditionally Exempt - Limited

- Conditionally Exempt - Small Quantity Treatment

- Conditionally Exempt - Specified Waste Streams

- Permit By Rule

Certification of Financial Assurance

Plot Plan/Map

Prior Enforcement History

Tank and Container Certification

Local Agency Notification

Property Owner Notification

Estimate of Closure Costs

Financial Assurance Closure Mechanism

Complete and maintain on site (do not submit in CERS)

Waste Analysis Plan

Closure Plan

Phase 1 Assessment

Additional Hazardous Waste Treatment Guidance Documents

Underground Storage Tank (UST) Forms

Complete in CERS in the Underground Storage Tanks section:

Operating Permit Application - Facility Information

Operating Permit Application -Tank Page

UST Monitoring System Plan

Complete form and upload in CERS in the Underground Storage Tanks section:

UST Monitoring System Emergency Response Plan HM-9222B

UST Monitoring System Plot (Site) Plan HM-9222C

Certification of Financial Responsibility

Sample Letter from the Chief Financial Officer

Statement of Understanding and Compliance (NEW)           Designated Underground Storage Operator Identification Form (NEW)

Complete form and send to HMD (mail, email or fax):

Spill Bucket Testing Report Form (UPDATED)            Overfill Prevention Equipment Inspection report Form (NEW)

Tank Integrity Test Report HM-965

UST Claim of Exemption Form HM-978

Temporary Closure of UST - Procedures & Application HM-9119

Unauthorized Release Forms and Instructions (UST Leak Reporting Form)

UST Monitoring System Certification (UPDATED)

UST Secondary Containment Testing Certification (UPDATED)

Affirmative Statement of UST Compatibility

UST Leak Detection Functionality HM-9326

Complete form and keep onsite for inspection review:

Designated Operator Training Description and Documentation HM-9177

Designated UST Operator Visual Inspection Form (NEW)            Facility Employee Certificate (NEW)

More information about the UST Program

Underground Storage Tank Plan Check Application Forms

Complete in CERS in the Underground Storage Tanks section:

UST Certificate of Installation / Modification

Complete form and send to HMD via email to [email protected]

Part I General project information HM-9311

Part II Construct a UST facility HM-9312

Part III Close a UST system HM-9313

Part IV Modify existing UST site HM-9314

Part V Interior coating/lining/repair UST HM-9315

Special Projects Assistance Program - Application HM-9170           UST Compatibility with Hazardous Substance for New Installations HMF-2020

More information about the UST Plan Check Program and UST Lining Inspection Requirements

Aboveground Petroleum Storage Act Forms

Complete and implement the appropriate form:

Tier I Facility Spill Prevention Control and Countermeasure (SPCC) Plan            Tier II Facility Spill Prevention Control and Countermeasure (SPCC) Plan            Certification of the Applicability of the Substantial Harm Criteria (Required at all APSA facilities)

For guidance on selecting the correct SPCC Plan for your facility and for more information about APSA, please visit our  Aboveground Petroleum Storage Program  page. Submit a completed Tank Facility Statement to the Aboveground Petroleum Storage Act Documentation link in the APSA section in CERS:

Tank Facility Statement (APSA)

(This form is optional if you rely on a submitted Hazardous Materials Business Plan (HMBP) in CERS to meet the annual Tank Facility Statement requirement.) APSA Checklists           STI SP001 AST Record STI SP001 Monthly AST Inspection Checklist STI SP001 Annual AST Inspection Checklist Monthly Visual (OSFM) Inspection Checklist for TIUGAs at Facilities with Less than 1,320 gallons Sample Monthly Aboveground Tank/Container Inspection Form Monthly Checklist for TIUGA Facility with Less than 1,320 Gallons of Petroleum ( Word | PDF )

Medical Waste Forms

Complete form and upload in CERS in the Hazardous Materials Inventory section under

Locally-Required Documentation:

Medical Waste Management Plan HMF-8005

Complete form and send to HMD (mail, email or fax):

Application for Home-Generated Sharps Consolidation Point HM-9158

Application for Onsite Medical Waste Treatment Permit HM-9188

Limited Quantity Hauling Exemption -Effective January 1, 2015, This form is no longer required. If you are a small or large quantity generator of medical waste, visit the CDPH Medical Waste Generators website for additional information.

More information about the Medical Waste Program and Medical Waste Guidance Documents