"Groundwater Remediation Loan Program Application Supplement Form" - California

Groundwater Remediation Loan Program Application Supplement Form is a legal document that was released by the California Department of Toxic Substances Control - a government authority operating within California.

Form Details:

  • Released on July 20, 2001;
  • The latest edition currently provided by the California Department of Toxic Substances Control;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of the form 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 "Groundwater Remediation Loan Program Application Supplement Form" - California

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CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
OPTIONAL FORM
DEPARTMENT OF TOXIC SUBSTANCES CONTROL
(Use of this form is not required.)
SITE MITIGATION PROGRAM
GROUNDWATER REMEDIATION LOAN PROGRAM
APPLICATION SUPPLEMENT
This is an optional document to assist in preparing an application package for the Groundwater Remediation Loan Program. Applicants are
responsible for reading the regulations and ensuring all applicable information is provided as outlined in the emergency regulations for this
program (Title 22, California Code of Regulations, sections 68300-68309). In addition to providing information requested on this form,
refer to Section 4. for a list of the attachments that are required as part of a complete application package. (Please use additional pages,
as necessary, to complete your responses.)
SECTION 1. APPLICANT INFORMATION
a. Applicant's Name
Address
Phone Number
b. Applicant's Relationship to Site:
[ ] Owner
[ ] Responsible Party
[ ] Other (Please Explain)___________________________________________
c. If the Applicant is not the current owner, provide the following:
Current Owner's Name
Address
Phone Number
d. Description of the applicant's activities and responsibilities relevant to the proposed project:
e. Provide name, address and resume of site coordinator:
f. List prior experience in implementing similar groundwater remediation projects:
g. List technical support personnel (by classification) who will be working on this project (provide copy of proposed organization
and resumes of key technical staff):
h. Signature of the Applicant
Date
A - 1
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Clear
CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
OPTIONAL FORM
DEPARTMENT OF TOXIC SUBSTANCES CONTROL
(Use of this form is not required.)
SITE MITIGATION PROGRAM
GROUNDWATER REMEDIATION LOAN PROGRAM
APPLICATION SUPPLEMENT
This is an optional document to assist in preparing an application package for the Groundwater Remediation Loan Program. Applicants are
responsible for reading the regulations and ensuring all applicable information is provided as outlined in the emergency regulations for this
program (Title 22, California Code of Regulations, sections 68300-68309). In addition to providing information requested on this form,
refer to Section 4. for a list of the attachments that are required as part of a complete application package. (Please use additional pages,
as necessary, to complete your responses.)
SECTION 1. APPLICANT INFORMATION
a. Applicant's Name
Address
Phone Number
b. Applicant's Relationship to Site:
[ ] Owner
[ ] Responsible Party
[ ] Other (Please Explain)___________________________________________
c. If the Applicant is not the current owner, provide the following:
Current Owner's Name
Address
Phone Number
d. Description of the applicant's activities and responsibilities relevant to the proposed project:
e. Provide name, address and resume of site coordinator:
f. List prior experience in implementing similar groundwater remediation projects:
g. List technical support personnel (by classification) who will be working on this project (provide copy of proposed organization
and resumes of key technical staff):
h. Signature of the Applicant
Date
A - 1
SECTION 2. SITE/PROJECT INFORMATION
a. Provide site description (attach locator map and map of proposed project area):
b. Is the proposed project a facility specific cleanup?
If so, attach a map showing location of facility and provide a legal
description of the property and identify assessor parcel numbers.
c. Provide current land uses in project area (where possible, identify the presence of sensitive receptors such as schools, hospitals,
daycare centers, etc. within the proposed project area):
d. Proposed Project Description/Statement of Work (attach separate sheet if necessary):
e. Previous Business Operations (if known, list all previous businesses operating on this property):
(Name)
(Business Type)
(Years of Operation)
f. Describe ability to obtain necessary permits if treated groundwater is to be reused as drinking water supply:
g. Describe ability to obtain necessary water rights to implement the proposed project:
h. What evidence do you have that the area for the proposed groundwater remediation project poses a risk or potential risk
to public health and the environment due to the release of hazardous substances?
What information is available, if any, to quantify this risk?
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SECTION 2. SITE/PROJECT INFORMATION, Continued from page 2
i. What is the estimated number of users impacted by the groundwater contamination?
j. Have any wells been taken out of service as a result of this contamination? Number of wells? Estimated capacity? Has water
supply capacity been negatively impacted in other ways? If so, how? Elaborate on the extent to which the proposed project
will reduce/prevent the migration of contaminants.
k. Public Involvement Activities (summarize recommended public involvement activities as outlined in the Department's Public
Participation Policy and Procedure Manual - attach document, if applicable)
SECTION 3. FINANCIAL INFORMATION
a. Provide supporting documentation about committing a source of funds for loan repayment
b. Provide information on existing bank loans and other types of debt, including names of bank officers and contact information
as appropriate (attach annual financial operating statements)
SECTION 4. REQUIRED DOCUMENTATION
- A letter requesting consideration for available loan funds with the signature of the applicant/authorized
representative.
- A certified copy of a resolution adopted by the governing authority of the applicant agency that authorizes
a representative (by title) to act on behalf of the applicant agency to sign document such as contracts, disbursement
requests, as well as assure compliance with applicable state statutory and regulatory requirements.
- A certified copy of a resolution adopted by the governing authority of the applicant agency that specifies the
authorized loan amount for the applicant agency.
- An ordinance or resolution committing a source or sources of funds for repayment. The ordinance or
resolution shall contain language equivalent to the following: "The (name of agency) hereby dedicates the following
source of revenue (list source or sources) for repayment of any and all groundwater remediation loans on the project
(identify the project name) to be funded through the Groundwater Remediation Loan Program.
- Copy of an appropriate map page and a legal description of the property, including assessor parcel
number(s).
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SECTION 4. REQUIRED DOCUMENTATION, Continued from page 3
- Brief analysis of engineering/project alternatives considered and an explanation of why the proposed
project description was chosen.
- Information regarding the impacts that the project site conditions or the proposed response actions may
have on: the geological features of the projects site; land use planning; public health and safety; the local population
and housing in the vicinity of the project site; water quality; air quality; traffic and transportation; ecological and
biological resources; energy and mineral resources; noise levels; public service systems and utilities; local
aesthetics; cultural resources; and recreation.
- A signed statement that the applicant agrees to waive any claims against, and hold harmless, the State of California,
including the Department and the State Water Resources Control Board, from and against any and all claims, costs,
and expenses stemming from operation, maintenance, or environmental degradation at the site.
- Proof of insurance for the applicant, naming the Department and the State Water Resources Control Board
as loss payee, up to the amount of the requested loan.
07/20/2001
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