DTSC Form 1360 "Publicly Owned Treatment Works (Potw) Partnership Sign up Form" - California

What Is DTSC Form 1360?

This is a legal form that was released by the California Department of Toxic Substances Control - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2003;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DTSC Form 1360 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

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Download DTSC Form 1360 "Publicly Owned Treatment Works (Potw) Partnership Sign up Form" - California

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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Publicly Owned Treatment Works (POTW) Partnership Sign Up Form
California Mercury (Hg) Elimination Leadership Program (HELP)
Attention all POTWs: If you have not already done so, please complete this sign up form and return it to the Department of
www.dtsc.ca.gov
Toxic Substances Control (DTSC). You may also go to our website at
to complete it.
Please check the appropriate responses, provide any relevant information and return this form to the Department of Toxic
Substances Control, Office of Pollution Prevention and Technology Development, P2CU – HELP Awards, P.O. Box 806,
Sacramento, California, 95812-0806.
POTW Name:
Street Address:
Check here if same as mailing address.
Mailing Address (if different from Street Address):
City:
Zip Code:
County:
Ongoing HELP Contact Name:
Contact Title:
Contact Telephone:
Extension:
Contact E-mail address:
DTSC may post our POTW’s name on your website as a partner in HELP that is working towards the goal of the
hospitals in our region becoming mercury-free by 2005.
These are some hospitals in my jurisdiction:
1. Hospital Name:
Hospital Address:
Hospital Contact Name:
Phone:
2. Hospital Name:
Hospital Address:
Hospital Contact Name:
Phone:
3. Hospital Name:
Hospital Address:
Hospital Contact Name:
Phone:
Our POTW is affected by a Mercury Total Maximum Daily Load (TMDL).
Water body affected is:
Our POTW is open to negotiating less restrictive mercury limits for hospitals within our service area who meet the
goals of HELP.
Our POTW is interested in a two hour training session on mercury source reduction for hospitals.
DTSC 1360 (5/03)
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Publicly Owned Treatment Works (POTW) Partnership Sign Up Form
California Mercury (Hg) Elimination Leadership Program (HELP)
Attention all POTWs: If you have not already done so, please complete this sign up form and return it to the Department of
www.dtsc.ca.gov
Toxic Substances Control (DTSC). You may also go to our website at
to complete it.
Please check the appropriate responses, provide any relevant information and return this form to the Department of Toxic
Substances Control, Office of Pollution Prevention and Technology Development, P2CU – HELP Awards, P.O. Box 806,
Sacramento, California, 95812-0806.
POTW Name:
Street Address:
Check here if same as mailing address.
Mailing Address (if different from Street Address):
City:
Zip Code:
County:
Ongoing HELP Contact Name:
Contact Title:
Contact Telephone:
Extension:
Contact E-mail address:
DTSC may post our POTW’s name on your website as a partner in HELP that is working towards the goal of the
hospitals in our region becoming mercury-free by 2005.
These are some hospitals in my jurisdiction:
1. Hospital Name:
Hospital Address:
Hospital Contact Name:
Phone:
2. Hospital Name:
Hospital Address:
Hospital Contact Name:
Phone:
3. Hospital Name:
Hospital Address:
Hospital Contact Name:
Phone:
Our POTW is affected by a Mercury Total Maximum Daily Load (TMDL).
Water body affected is:
Our POTW is open to negotiating less restrictive mercury limits for hospitals within our service area who meet the
goals of HELP.
Our POTW is interested in a two hour training session on mercury source reduction for hospitals.
DTSC 1360 (5/03)