Okaloosa County BOCC — September 16, 2014 — 2014-2015 Hazards Analysis Agreement — reading text

The prospective subcontractor of the Recipient, ____________________________, certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the Recipient’s subcontractor is unable to certify to the above statement, the prospective subcontractor shall attach an explanation to this form. SUBCONTRACTOR: ______________________________ By:____________________________ Okaloosa County Signature Recipient’s Name ________________________________ 15-CP-11-01-56-01-XXX Name and Title DEM Contract Number ________________________________ __________________________________ Street Address Project Number ________________________________ City, State, Zip ________________________________ Date 31  Attachment H Statement of Assurances The Recipient hereby assures and certifies compliance with all Federal statutes, regulations, policies, guidelines and requirements, including OMB Circulars No. A-21, A-110, A-122, A-128, A-87; E.O. 12372 and Uniform Administrative Requirements for Grants and Cooperative Agreements 28 CFR, Part 66, Common rule, that govern the application, acceptance and use of Federal funds for this federally-assisted project. Also the Applicant assures and certifies that: 1. It will comply with provisions of Federal law which limit certain political activities of employees of a State or local unit of government whose principal employment is in connection with an activity financed in whole or in part by Federal grants. (5 USC 1501,et. seq.) 2. It will comply with the minimum wage and maximum hour’s provisions of the Federal Fair Labor Standards Act. 3. It will establish safeguards to prohibit employees from using their positions for a purpose that is or gives the appearance of being motivated by a desire for private gain for themselves or others, particularly those with whom they have family, business, or other ties. 4. It will give the sponsoring agency or the Comptroller General, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the grant. 6. It will ensure that the facilities under its ownership, lease or supervision which shall be utilized in the accomplishment of the project are not listed on the Environmental Protection Agency's (EPA) list of Violating Facilities and that it will notify the Federal grantor agency of the receipt of any communication from the Director of the EPA Office of Federal Activities indicating that a facility to be used in the project is under consideration for listing by the EPA. 7. In the event a Federal or State court or Federal or State administrative agency makes a finding of discrimination after a due process hearing on the Grounds of race, color, religion, national origin, sex, or disability against a recipient of funds, the recipient will forward a copy of the finding to the Office for Civil Rights, Office of Justice Programs. 8. It will provide an Equal Employment Opportunity Program if required to maintain one, where the application is for $500,000 or more. 9. DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS) As required by the Drug-Free Workplace Act of 1988, and implemented at 28 CFR Part 67, Subpart F, for grantees, as defined at 28 CFR Part 67 Sections 67.615 and 67.620. 32  Attachment I Hazard Analysis Contract Checklist and CAMEOfm Guide Facility Information (CAMEOfm Facility Page) Facility Name {per Attachment C} ( Facility Page) Facility Physical Address (Facility Page) Latitude and Longitude in Decimal Degrees {ex. 30.197, ‐84.3621} (Map Data Tab on Facility Page) Facility Phone Number (Facility Phones Tab on Facility Page) Facility Emergency Coordinator Name, Title and 24‐hour Emergency Phone Number (Contact Tab on Facility Page) Transportation Route(s) {From County Line to the Facility} (Notes Tab on Facility Page) Evacuation Route(s) to exit the Vulnerable Zone (Notes Tab on Facility Page) Historical Accident Record {If none, please note} (Notes Tab on Facility Page) Facility Maximum Occupancy {a minimum of one is required for unmanned facilities} (ID Codes Tab on facility Page) Hazard Identification (CAMEOfm Chemical in Inventory Page) (for each Extremely Hazardous Substance on site) Proper Chemical Name(s) (Chemical in Inventory Page{s}) Chemical Abstract Service (CAS) Number (Chemical in Inventory Page{s}) Physical State in Storage {ex. mixture, pure, liquid, gas} (Chemical in Inventory Page{s}, Physical State and Quantity Tab) Maximum Quantity On‐site in Pounds (Chemical in Inventory Page{s}, Physical State and Quantity Tab) Amount in Largest Container or Interconnected Containers (Chemical in Inventory Page{s}, Physical State and Quantity Tab) Type/Design, Pressure and Temperature of Container(s) {cylinder, battery, ambient etc.} (Chemical in Inventory Page{s}, Location Tab) Nature of the Hazard {ex. acute, chronic, fire, pressure, etc.} Chemical in Inventory Page{s}, Physical State and Quantity Tab) Vulnerability Analysis (CAMEOfm Scenario Page) (for each Extremely Hazardous Substance on site) Enter maximum amount in largest container or interconnected containers in the Amount Released field (Scenario Description tab) Enter the concentration percentage in the Concentration field (Scenario Description tab) Enter Release Duration (10 minutes for gases, solids in solution or powders; no entry for liquids is required) (Scenario Description tab) Determine the natural Physical State (specified in CAMEO Chemicals) and enter into the Physical State field (Scenario Description tab) Weather Information ‐ Use the weather default settings or enter average wind speed (don’t enter a value in the Wind From field) and Urban or Forest is recommended in the Ground Roughness field. (Scenario Description tab) Risk Assessment ‐ Rate the Risk, Consequences and Overall Risk of a release occurring {based upon release history & maintenance etc.} (Scenario Description tab) Extent of Vulnerable Zone {CAMEO automatically calculates Threat Zone Radius when Edit button and Estimate Threat Zone Radius buttons are used} (Scenario Description tab) Enter estimate of Total Exposed Population (Notes Tab on Scenario Page{s}) Enter Critical Facilities {name of critical facility(s) and max occupancy for each; if none, state No Critical Facilities} (Notes Tab on Scenario Page{s}) On‐Site Visits (for each Facility and within the Contract Period) Site Visit Certification Form (Attached to Site Plan Tab on Facility Page) {file name must contain at minimum the SERC number if applicable and SV – if SERC number is not available facility name and SV – additional info allowed but not required.} Site Plan (Attached to Site Plan Tab on Facility Page) {file name must contain at minimum the SERC number if applicable and SP – if SERC number is not available the facility name and SP – additional info allowed but not required.} Sufficient Detail to Identify: Location of Major Building(s) Name and Location of Extremely Hazardous Substance(s) (if extremely hazardous materials are co‐located, noting EHS is acceptable) Name and Location of Street(s) Identify Pertinent Access and Egress Points Note Additional Features Pertinent to Hazardous Materials and Medical Response All data shall be submitted electronically via CAMEOfm version 3.0.1 in a .zip file format. 33  Attachment J FLORIDA STATE EMERGENCY RESPONSE COMMISSION FOR HAZARDOUS MATERIALS HAZARDS ANALYSIS SITE VISIT CERTIFICATION FORM Facility Name (Please print) Street Address, City & Zip Code (Please print) _________________________ County (Please print) Name of Facility Representative (Please print) Facility Representative Signature Site Visit Date Site Visit Performed by (Please print) Signature Site Visit Date The individuals signing above certify that a hazards analysis site visit was conducted on the above date. Notes:________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________  Check if facility representative was informed about using E-Plan (https://erplan.net/eplan/login.htm) for EPCRA on-line filing 34  Attachment K STATEMENT OF DETERMINATION Facility Name Physical Address (Street only) City County LEPC District I have determined that this facility is / is not subject to the following section(s) of EPCRA, Title III, for the reporting year(s) indicated (circle all applicable): SECTION 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 302 / 303 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 311 / 312 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 313 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N If “No” was indicated on any of the above, please check appropriate box(s) why: Sections Extremely Hazardous Substances (EHSs) are / were present only in amounts less than established 302/303 Threshold Planning Quantities (TPQs). No EHSs are Present. No EHSs were present on-site during the year. Sections Hazardous chemicals/EHSs are/were present only in amounts below established reporting thresholds. 311/ 312 No hazardous chemicals/EHSs are/were present. No hazardous chemicals were present on-site during the year. Section Not within covered SIC Codes. 313 Within covered SIC Codes, but less than ten (10) employees. Within covered SIC Codes, but no Section 313 chemicals were present or were below Section 313 reporting thresholds. Other Closed facility Chemicals removed Chemicals reduced below Date Effective: YES / NO YES / NO threshold/TPQ YES / NO New Facility. Date chemicals brought on site meeting / exceeding TPQ: Further explanation if necessary: ____________________________________________________________________________ ________________________________________________________________________