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Forms

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
  • 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 over 1,320 gallons (APSA/SPCC)

Many of the forms previously available through the 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 the address on the DEH "Contact Us" page. Ask your Specialist for the best FAX number or e-mail address to use.

Forms by Subject

»Aboveground Petroleum Storage Act»Medical Waste
»CalARP»OnSite Hazardous Waste Treatment
»General Business»Underground Storage Tanks
»Hazardous Materials»UST Plan Check Permit Application
»Hazardous Waste 

 

***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 Access/I.D. Request Form HM-907  PDF | WORD
          Corrective Action Form to Document Return to Compliance HM-926  PDF | WORD
          Hazardous Materials Questionnaire HM-9171  PDF | WORD
          Tenant improvement and new business forms and information  

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Hazardous Materials Forms including Business Plan
          Hazardous Materials Business Plan (HMBP) Instructions and Templates HM-952  PDF
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  PDF | WORD (Multi-page site maps should be uploaded as a single document)
          Remote Site Notification HM-9283  PDF
          Disclosure of Hazardous Materials Information Bulletin HM-9243  PDF | WORD
          (HM-9243 includes Carcinogen & Reproductive Toxin Report and Highly Toxic Gases)
Complete form and upload in CERS in the Emergency Response and Training Plans sections:
          Consolidated Emergency Response/Contingency Plan

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CalARP Forms
Complete form and send to HMD (mail, email or fax):
          CalARP Screening, Disclaimer and Deregistration Guide HM-9220  PDF | WORD
          CalARP Screening, Disclaimer and Deregistration Form HM-9221  PDF | WORD
          How to Determine TQs & TPQs HM-9181  PDF
          CalARP Screening Worksheet HM-9223  PDF | WORD
          Risk Management Plan (RMP) Work Plan HM-9240  PDF | WORD
More information about HMD's CalARP Program and Hazardous Materials Guidance Documents

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Hazardous Waste Forms
Complete in CERS in the Remote Waste Consolidation Site Annual Notification section:
          Remote Waste Consolidation Site Annual Notification Form HM-9714  PDF | WORD
Complete form and upload in CERS in the Hazardous Waste Tank Closure Certification section:
          Hazardous Waste Tank Closure Certificate
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):
          Photographic Waste Only - Notification HM-9281  PDF | WORD
          Aerosol Can Processing - Notification HM-9284  PDF | WORD
          AST Certification & Engineering Assessment Exemption - Notification HM-9271  PDF
Complete form and keep onsite for inspection review:
          Hazardous Waste Container Weekly Inspection Log HM-9322PDF
          Hazardous Waste Tank System Daily Inspection Log HM-9321  PDF
More information about HMD's Hazardous Waste Inspection Program and additional Hazardous Waste Guidance Documents

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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
          Certification of Financial Assurance
          Conditionally Authorized
          Conditionally Exempt - Limited
          Conditionally Exempt - Small Quantity Treatment
          Conditionally Exempt - Specified Waste Streams
          Permit By Rule
          Plot Plan/Map
          Prior Enforcement History
          Tank and Container Certification
          Local Agency Notification
          Property Owner Notification
          Closure Plan
          Estimate of Closure Costs
          Financial Assurance Closure Mechanism
          Waste Analysis Plan
Additional Tiered Permitting Guidance Documents

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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 PDF | WORD
          UST Monitoring System Plot (Site) Plan HM-9222C  PDF | WORD
          Certification of Financial Responsibility
          Sample Letter from the Chief Financial Officer
          Designation of UST Operator & Owner Statement
Complete form and send to HMD (mail, email or fax):
          Claim of Exemption from UST Regulations & Law HM-978  PDF
          Spill Bucket Testing Report Form HM-9010  PDF
          Tank Integrity Test Report HM-965  PDF
          Temporary Closure of UST - Application Cover Sheet & Procedures HM-9119  PDF
          Temporary Closure of UST - Application HM-9119a  PDF
          Unauthorized Release Forms and Instructions (UST Leak Reporting Form)
          UST Monitoring System Certification HM-9301  PDF | WORD
          UST Secondary Containment Testing Certification HM-9169  PDF | WORD
          Affirmative Statement of UST Compatibility HM-9325 PDF
          UST Leak Detection Functionality HM-9326PDF
Complete form and keep onsite for inspection review:
          Designated Operator Training Description and Documentation HM-9177  PDF
          Designated UST Operator Monthly Visual Inspection Checklist HM-9175  PDF
More information about HMD's UST Program

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Underground Storage Tank Plan Check Application Forms
Complete form and upload in CERS in the Underground Storage Tanks section:
          UST Certificate of Installation / Modification HM-9716  PDF | WORD
Complete form and send to HMD (mail, email or fax):
          Part I General project information HM-9311  PDF | WORD
          Part II Construct a UST facility HM-9312   PDF | WORD
          Part III Close a UST system HM-9313   PDF | WORD
          Part IV Modify existing UST site HM-9314   PDF | WORD
          Part V Interior coating/lining/repair UST HM-9315  PDF | WORD
          Part VI Construct vaulted UST facility HM-9316  PDF
          Part VII Install a UST bladder HM-9317  PDF
          Special Projects Assistance Program - Application HM-9170  PDF
More information about HMD's UST Plan Check Program and UST Lining Inspection Requirements

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Aboveground Petroleum Storage Act Forms
Complete form and upload in CERS in the Aboveground Petroleum Storage Act section:
          Tank Facility Statement (APSA) HM-9501  PDF | WORD
Complete form and keep onsite for inspection review:
           Tier I Facility Spill Prevention Control and Countermeasure (SPCC) Plan
           Tier II Facility Spill Prevention Control and Countermeasure (SPCC) Plan
More information about the Aboveground Petroleum Storage Program

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Medical Waste Forms
Complete form and upload in CERS in the Hazardous Materials Inventory section
under Locally-Required Documentation:
          Application for a Limited Quantity Hauling Exemption HM-9156  PDF
          Medical Waste Management Plan HM-9213  PDF | WORD
Complete form and send to HMD (mail, email or fax):
          Application for Home-Generated Sharps Consolidation Point HM-9158  PDF | WORD
          Application for Onsite Medical Waste Treatment Permit HM-9188  PDF | WORD
More information about HMD's Medical Waste Inspection Program and Medical Waste Guidance Documents

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