BAY AREA AIR QUALITY MANAGEMENT DISTRICT
375 Beale Street, Suite 600, San Francisco, CA 94105. . . (415) 749-4990 . . . FAX (415) 749-5030 OR 4949
WEBSITE: WWW.BAAQMD.GOV
Health Risk Screening Analysis
IMPORTANT: For any permit application that requires a Health Risk Screening Analysis, fill out one form for
each source that emits a Toxic Air Contaminant(s) [or for a group of sources that exhaust through a common
stack]. Emissions can be from a discrete point source (with stack) or a source with fugitive emissions (area or
volume source). You must provide a plot plan (drawn to scale, if possible) and a local map (aerial photos are
recommended), which clearly demonstrate the location of your site, the source(s), property lines, and any
surrounding buildings [see attached example]. Label streets, schools, residences, and other businesses. List
major dimensions of all buildings surrounding the source in Section C.
Plant Name: Plant No.:
Source Description:
Source No.: S- Emission Point No.: P-
(if known) (if known)
SECTION A (Point Source)
1. Does the source exhaust at clearly defined emission point; i.e., a stack or exhaust pipe? YES OR NO
(If YES continue at #2, If NO, skip to Section B)
2. Does the stack (or exhaust pipe) stand alone or is it located on the roof of a building? alone OR on roof
Important: If stack is on a roof, provide building dimensions on line B1 in Section C.
3. What is the height of the stack outlet above ground level? feet OR meters?
4. What is the inside diameter of the stack outlet? inches OR feet OR meters
5. What is the direction of the exhaust from the stack outlet? horizontal OR vertical
6. Is the stack outlet: open or hinged rain flap OR rain capped (deflects exhaust downward or horizontally)
7. What is the exhaust flowrate during normal operation? cfm (cubic feet/min) OR meters
3
/second
8. What is the typical temperature of the exhaust gas? degrees Fahrenheit OR degrees Celsius
(Skip Section B and Go on to Section C)
SECTION B (Area/Volume Source)
This section applies to fugitive emissions that are NOT captured by a collection system nor directly emitted through a stack or
other emission point. Volume sources have fugitive emissions generally released within a building or other defined space
(e.g., dry cleaner, gasoline station canopy). Area sources are generally flat areas of release (e.g., landfill, quarry).
1. Is the emission source located within a building? YES (go to #2) OR NO (go to #3)
2. If YES (source inside building), provide building dimensions on line B1 in Section C
a. Does the building have a ventilation system that is vented to the outside? YES OR NO
b. If NO (ventilation), are the building's doors & windows kept open during hours of operation? YES OR NO
3. If NO (source not inside building), provide a description of the source, dimensions, & indicate location on plot plan.
