Form DTSC1151 "Tiered Permitting Phase I Environmental Assessment Checklist" - California

What Is Form DTSC1151?

This is a legal form that was released by the California Department of Toxic Substances Control - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 1999;
  • 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;

Download a printable version of Form DTSC1151 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 Form DTSC1151 "Tiered Permitting Phase I Environmental Assessment Checklist" - California

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State of California-California Environmental Protection Agency
Department of Toxic Substances Control
TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST
SECTION I: FACILITY INFORMATION
Instructions: Complete the following descriptive information about your facility. This information accurately describes the location of your facility
and establishes mailing and phone contacts. If facility location and mailing address are identical, you may put "same" into facility mailing address
spaces.
Type of Permit:
Permit by Rule _____
Conditional Authorization _____
1. CURRENT FACILITY NAME:
PAST NAMES (
):
Attach additional pages if necessary
2. EPA I.D. NUMBER:
3. NAME OF FACILITY OWNER (
):
see definition of owner
4. NAME OF FACILITY OPERATOR:
5. NAME OF PROPERTY OWNER:
6. FACILITY LOCATION ADDRESS:
STREET:
CITY:
COUNTY:
STATE:
ZIP CODE:
7. FACILITY MAILING ADDRESS (
FACILITY LOCATION ADDRESS):
if different from
STREET:
CITY:
STATE:
ZIP CODE:
8. FACILITY TELEPHONE NUMBER:
9. FACILITY FAX NUMBER:
10. NAME OF FACILITY CONTACT PERSON:
11. TITLE OF FACILITY CONTACT PERSON:
12. PHONE NUMBER OF FACILITY CONTACT PERSON:
DTSC 1151 (06/99)
Please indicate total number of pages _____of_____
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST
SECTION I: FACILITY INFORMATION
Instructions: Complete the following descriptive information about your facility. This information accurately describes the location of your facility
and establishes mailing and phone contacts. If facility location and mailing address are identical, you may put "same" into facility mailing address
spaces.
Type of Permit:
Permit by Rule _____
Conditional Authorization _____
1. CURRENT FACILITY NAME:
PAST NAMES (
):
Attach additional pages if necessary
2. EPA I.D. NUMBER:
3. NAME OF FACILITY OWNER (
):
see definition of owner
4. NAME OF FACILITY OPERATOR:
5. NAME OF PROPERTY OWNER:
6. FACILITY LOCATION ADDRESS:
STREET:
CITY:
COUNTY:
STATE:
ZIP CODE:
7. FACILITY MAILING ADDRESS (
FACILITY LOCATION ADDRESS):
if different from
STREET:
CITY:
STATE:
ZIP CODE:
8. FACILITY TELEPHONE NUMBER:
9. FACILITY FAX NUMBER:
10. NAME OF FACILITY CONTACT PERSON:
11. TITLE OF FACILITY CONTACT PERSON:
12. PHONE NUMBER OF FACILITY CONTACT PERSON:
DTSC 1151 (06/99)
Please indicate total number of pages _____of_____
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST
13. ADDRESS OF FACILITY CONTACT PERSON:
STREET:
CITY:
STATE:
ZIP CODE:
SECTION II: FACILITY HISTORY
Instructions: Complete this section regarding facility history based on reasonably available knowledge of the facility. This section will determine if
past operating practices and significant historical events that occurred at the facility indicate potential areas of contamination. Current and past
employees who know about the facility's past operating practices can be an asset in completing this section of the checklist. Yes answers to these
questions mean that careful attention must be paid to these areas and considerations when completing the facility walk-through inspection.
YES
NO
1.
Has an environmental assessment and/or a site investigation report ever been completed
for the facility? If this assessment meets the criteria for substituting for this checklist
(see Instructions), use the Signature and Certification Page to record this exemption. You
need not release confidential assessments. However, if these reports indicate existing or
potential contamination, you must use the information relied on by the confidential report
to help reach a conclusion in this assessment.
2.
To your knowledge, have areas of the facility that contain hazardous materials ever been
flooded?
3.
To your knowledge, has the facility ever been damaged by an earthquake that could
cause contamination?
4.
To your knowledge, has the location for the facility ever been used for industrial
purposes prior to its current use? If YES, then consider potential contamination from the
type of industry that the location was formerly used for.
5.
To your knowledge, has there been any disposing of hazardous chemicals or hazardous
wastes in, on, or under the property?
6.
To your knowledge, has the facility ever had electrical transformers, capacitors, or
hydraulic equipment including, but not limited to elevators and auto lifts, at the facility
which may have released PCBs or oil to the environment? (Not including small quantities
of fluorescent light ballasts and capacitors if these materials were not disposed of or
dismantled at the facility)
If YES, was the equipment ever tested for the presence of PCBs?
7.
To your knowledge, has testing of any groundwater wells on the property ever revealed
possible contamination?
8.
Do you have in your possession, or do you know of the existence of any photographs,
geophysical reports, analytical test data, and/or air sampling data that indicates the
possible presence of hazardous materials and/or waste in unwarranted or unexpected
areas of the facility?
9.
To your knowledge, has the facility ever had liquid/sludge containment area(s), surface
impoundment(s), collection pond(s), and/or lagoon(s)?
DTSC 1151 (06/99)
Please indicate total number of pages _____of_____
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST
10.
To your knowledge, have land-farming or bioremediation been used at the facility?
11.
To your knowledge, has the facility ever burned hazardous wastes, unidentified waste
materials, tires, or automotive batteries at the facility?
12.
To your knowledge, have ash and/or combustion residuals been disposed of at the
facility?
13.
To your knowledge, have any underground storage tank(s) been removed, abandoned, or
taken out of service from the facility? Tanks removed, abandoned, or taken out of service
under the oversight of a responsible agency need not be considered if the agency
addressed potential contamination at the tank location.
14.
To your knowledge, has any contaminated soil been discovered and/or remediated at the
facility without oversight by an appropriate regulatory agency?
15.
To your knowledge, have there been fires and/or explosions at the facility which may
have caused a release of hazardous waste or materials?
16.
To your knowledge, has the facility ever received complaints from any employees,
neighbors, or the public about the facility's practices for managing hazardous wastes, or
any actual or potential releases to air, water, or soil, or other environmental issues?
17.
To your knowledge, have nearby residents complained to a governmental agency of any
type of illnesses or unusual illnesses as having been caused or suspectedly caused by or
related to activities at the facility? (Note: this item does not require questioning the
facility's neighbors) If YES, indicate below the person and/or agency who recorded the
complaint.
If YES, to your knowledge, has any evidence been submitted to a physician to
substantiate the claim?
18.
To your knowledge, are there any areas at the facility which were formerly used for
hazardous waste or hazardous materials transfer (e.g. tank loading areas, drum transfer
areas)?
19.
To your knowledge, are there, or have there been lawsuits or administrative proceedings
concerning an actual, alleged, or threatened release of any hazardous substance against
the facility by another party? Only actions concluded by settlement or litigation need be
considered.
DTSC 1151 (06/99)
Please indicate total number of pages _____of_____
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST
SECTION IV: FACILITY WALK-THROUGH INSPECTION - OTHER AREAS
Instructions: This section of the checklist requires the owner and/or operator of the facility to conduct a walk-through inspection of the those
portions of the facility not addressed in Section III in order to identify possible environmental problems, environmental warning signs or potential
exposure to people, animals, or plants. Some of the problems that may be discovered during this inspection include abandoned storage tanks, spill
areas, surface impoundments, etc. Some of the environmental warning signs include stains, discolored vegetation, and/or unnatural terrain. During the
inspection, were any of the following present:
YES
NO
1.
Does the facility have vent pipes, fill pipes, and/or access routes that may indicate
the presence of an underground storage tank?
2.
Does the facility have stains and/or discolorations of the soil, flooring, drains
and/or walls at the facility which may indicate a release to the environment that
has not or is not being addressed under the oversight of an appropriate agency?
3.
Does the facility have areas of soil at the facility that appear disturbed and which
may indicate onsite disposal or land treatment of hazardous materials or
remediation of releases without oversight by an appropriate agency?
4.
Does the facility have areas at the facility where the terrain appears unnatural,
such as unexplained mounds or depressions?
5.
Does the facility have unusual smells or odors emanating from the soil, floor,
drains, and/or walls at the facility?
6.
Does the facility have dead, abnormal, or distressed-looking vegetation or
conspicuous absence of vegetation at the facility that is not directly explainable
by a deliberate action and/or lack of water at the site?
7.
Where does rain and/or washwater drain to at the facility? (circle all that apply) Note: slightly contaminated
storm or washwater can seriously contaminate evaporation or settling areas (with no drainage) over a period of
time.
a. Storm Drain
d. Open Land
b. Sewer
e. Areas of pooling, settling, or evaporation
c. Drainage Ditch
f. Other _________________________________
DTSC 1151 (06/99)
Please indicate total number of pages _____of_____
State of California-California Environmental Protection Agency
Department of Toxic Substances Control
TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST
AREA OF CONCERN DATASHEET
Instructions: Complete the following questions in detail for EACH release or suspected release identified in Section III FACILITY WALK-
THROUGH INSPECTION - SPECIFIC AREAS or SECTION IV FACILITY WALK-THROUGH INSPECTION - OTHER AREAS and any
other known or suspected releases. Do not include areas that have been or are being remediated under the oversight of an appropriate
agency.
If answers to questions are not known, then state "unknown".
1.
Facility name:
2.
This sheet is being completed for a:
Known release _____
Suspected release _____
3.
How was this release or suspected release discovered?
During the walk-through inspection? _____
Previously known release? _____
What checklist question(s) are related to this release (section/question)__________________________
4.
When did the release occur?
5.
What was released and how much?
6.
What caused the release?
7.
Indicate the approximate area of the release (e.g. 3 feet in diameter, 5 feet X 4 feet.)
8.
Was the release remediated? If YES, explain how. (Note: A datasheet need not be completed for
releases remediated or being remediated under the oversight of an appropriate agency.
9.
Were samples collected? If yes, what were the results?
10.
List any environmental reports or studies performed on the area of concern and attach copies or summaries of
the reports not submitted to the Department.
Name of preparer:
Title of preparer:
Date:
DTSC 1151 (06/99)
Please indicate total number of pages _____of_____