Aboveground Monitoring Plan

Aboveground Separation, Containment, and Monitoring Plan (Appendix to Hazardous Materials Business Plan and Hazardous Materials Registration Form) For use by Unidocs Member Agencies in Santa Clara County and where Required by your Local Jurisdiction Page of Facility Name:

Complete one column for each aboveground storage area shown on the Hazardous Materials Business Plan or Hazardous Materials Registration Form Storage Map(s). Write the appropriate location code in the box provided at the top of each column; then moving down the column, check all boxes which apply to that location. Make additional copies of this page if needed.

Location

Storage Inside building Inside building Inside building Inside building Inside building Type Outside shed/shelter Outside storage shed Outside storage shed Outside storage shed Outside storage shed Outdoors Outdoors Outdoors Outdoors Outdoors Primary Original containers Original containers Original containers Original containers Original containers Containment Safety cans Safety cans Safety cans Safety cans Safety cans (Check all Inside machinery Inside machinery Inside machinery Inside machinery Inside machinery that apply) Drums/barrels Drums/barrels Drums/barrels Drums/barrels Drums/barrels Pressure vessels Pressure vessels Pressure vessels Pressure vessels Pressure vessels Tanks Bulk tanks Bulk tanks Bulk tanks Bulk tanks Aboveground piping Aboveground piping Aboveground piping Aboveground piping Aboveground piping Other Other Other Other Other Secondary Approved cabinets Approved cabinets Approved cabinets Approved cabinets Approved cabinets Containment Secondary drum Secondary drum Secondary drum Secondary drum Secondary drum (Check all Tray Tray Tray Tray Tray that apply) Bermed & coated floor Bermed & coated floor Bermed & coated floor Bermed & coated floor Bermed & coated floor Tank vault Tank vault Tank vault Tank vault Tank vault Secondary piping or Secondary piping or Secondary piping or Secondary piping or Secondary piping or piping trench piping trench piping trench piping trench piping trench Other Other Other Other Other Separation All materials compatible All materials compatible All materials compatible All materials compatible All materials compatible (Check all One-hour separation One-hour separation One-hour separation One-hour separation One-hour separation that apply) wall/partition wall/partition wall/partition wall/partition wall/partition Separation by at least 20 Separation by at least 20 Separation by at least 20 Separation by at least 20 Separation by at least 20 feet feet feet feet feet Approved cabinets Approved cabinets Approved cabinets Approved cabinets Approved cabinets Other Other Other Other Other Monitoring Visual Visual Visual Visual Visual Type Automatic sensors Automatic sensors Automatic sensors Automatic sensors Automatic sensors Other Other Other Other Other Monitoring Daily Daily Daily Daily Daily Frequency Weekly Weekly Weekly Weekly Weekly Monthly Monthly Monthly Monthly Monthly Continuous Continuous Continuous Continuous Continuous Other Other Other Other Other

In the space provided below, describe the location, type, manufacturer’s specifications (if applicable) and suitability of any monitoring methods used other than visual monitoring. Attach additional pages if needed:

UN-021 - 1/1 www.unidocs.org Rev. 07/24/06