Form HRSA
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.
(Go on to Section C)
HRSA-1
SECTION C (Building Dimensions)
Provide building dimensions. Use Line B1 only for building with source/stack on the roof or with fugitive emissions inside
building. Use Lines B2-B9 for buildings surrounding the source (within 300 feet). Distance and direction are optional if map
and/or aerial photo are adequately labeled with locations of buildings. Check one for units: feet OR meters
B#
Building name or description
Width
Distance
To Source
Direction
To Source
B1
Building with source:
n/a
n/a
B2
B3
B4
B5
B6
B7
B8
B9
NOTE: Label buildings by B# on plot plan, map and/or aerial photo. Provide comments below for any details that
need additional clarification (e.g., list buildings that are co-occupied by your employees and other workers,
residents, students, etc).
(Go on to Section D)
SECTION D (Receptor Locations)
NOTE: Indicate on maps or aerial photos the residential and nonresidential areas surrounding your facility.
1. Indicate the area where the source is located (check one):
zoned for residential use zoned for mixed residential and commercial/industrial use
zoned for commercial and/or industrial use zoned for agricultural use
2. Distance from source (stack or building) to nearest facility property line = feet OR meters
3. Distance from source (stack or building) to the property line of the nearest residence = feet OR meters
4. Describe the nearest nonresidential property (check one): Industrial/Commercial OR Other
5. Distance from source (stack or building) to property line of nearest nonresidential site = feet OR meters
6. Distance from source to property line of nearest school* (or school site) = feet OR Greater than 1,000 feet
[Note: Helpful website with California Dept. of Education data: www.greatschools.net]
Provide the names and addresses of all schools
*
that have property line(s) within 1,000 feet of the source:
*K-12 and more than twelve children only HRSA-101205
HRSA-2
EXAMPLE:
Check one for units: X feet OR meters
B#
Building or Description
Height
Width
Length
Distance to
Source
Direction to
Source
B1
Building with source:
Frazier Plating, shop
25
100
100
N/a
N/a
B2
Frazier Plating, office
15
50
175
40
N
B3
7-Eleven
20
50
225
100
N
B4
Ye Old Oak Cooper
12
63
225
100
W
B5
Floyd’s Barber Shop
10
69
112
225
NE
B6
Goober’s Car Care
15
175
225
220
E
B7
Exito Enterprises
13
115
275
220
SE
B8
Residential (9 Apartment Bldgs)
32
60
130
Various
S
Frazier Plating, 955 Duncan Blvd, Mayberry, CA
HRSA-3
USGS map courtesy of Terraserver-USAS at http://terraserver-usa.com/
HRSA-4