DTSC Form 1381 "Environmental Oversight Program Application" - California

What Is Form DTSC1381?

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 September 12, 2014;
  • 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 fillable version of Form DTSC1381 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 1381 "Environmental Oversight Program Application" - California

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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
ENVIRONMENTAL OVERSIGHT PROGRAM APPLICATION
SCHOOL PROPERTY EVALUTION AND CLEANUP DIVISION
The purpose of this application is to obtain information necessary to determine the eligibility of the site for acceptance into
the Environmental Oversight Program. Please use additional pages, as necessary, to complete your responses.
SECTION 1
PROPONENT INFORMATION
Proponent Name
Principal Contact Name
Phone
(
)
-
Street Address
City
State
Zip Code
Proponent’s relationship to site
Designated Agreement Manager Name
Title
Brief statement of why the proponent is interested in DTSC services related to site
Contact information for DTSC billing purposes
Contact Name
Phone
(
)
-
Department
Street Address
City
State
Zip Code
SECTION 2
SITE INFORMATION
Is this site listed on EnviroStor?
Yes
No
If yes, provide EnviroStor Name
EnviroStor Number
Site Name
Street Address
City
County
Zip Code
Assessor’s Parcel Number(s)
Please attach a site location map and a current site plan
DTSC 1381 (09/12/14)
page 1 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
ENVIRONMENTAL OVERSIGHT PROGRAM APPLICATION
SCHOOL PROPERTY EVALUTION AND CLEANUP DIVISION
The purpose of this application is to obtain information necessary to determine the eligibility of the site for acceptance into
the Environmental Oversight Program. Please use additional pages, as necessary, to complete your responses.
SECTION 1
PROPONENT INFORMATION
Proponent Name
Principal Contact Name
Phone
(
)
-
Street Address
City
State
Zip Code
Proponent’s relationship to site
Designated Agreement Manager Name
Title
Brief statement of why the proponent is interested in DTSC services related to site
Contact information for DTSC billing purposes
Contact Name
Phone
(
)
-
Department
Street Address
City
State
Zip Code
SECTION 2
SITE INFORMATION
Is this site listed on EnviroStor?
Yes
No
If yes, provide EnviroStor Name
EnviroStor Number
Site Name
Street Address
City
County
Zip Code
Assessor’s Parcel Number(s)
Please attach a site location map and a current site plan
DTSC 1381 (09/12/14)
page 1 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
SECTION 2
SITE INFORMATION (continued)
Current Owner
Contact Name
Phone
(
)
-
Street Address (mailing)
City
State
Zip Code
Background and Previous Business Operations
Name
Type
Years of Operation
If known, list all previous businesses operating on site
What hazardous substances/wastes have been associated with the site?
What environmental media is/was/may be contaminated?
air
groundwater
soil
surface water
Has sampling or other investigations been conducted?
Yes
No
Specify
If yes, what hazardous substances have been detected and what were their maximum concentrations?
Are any federal, state, or local regulatory agencies currently involved with the site?
Yes
No
If yes, provide the agency name, involvement, and contact names and telephone numbers below:
Agency
Involvement
Contact Name
Phone
(
)
-
(
)
-
(
)
-
DTSC 1381 (09/12/14)
page 2 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
How many future students and classrooms will the site accommodate?
What is the anticipated opening date?
What oversight service is being requested of the Department?
PEA
RI/FS
Removal Action
Remedial Action
RAP
Certification
Other (describe the proposed project)
Is there currently a potential of exposure of the community or workers to hazardous substances at the site?
Yes
No
If yes, please explain
SECTION 3
COMMUNITY INFORMATION
Describe the site property (include approximate size)
Describe the surrounding land use (including proximity to residential housing, schools, day care facilities, churches,
etc.)
Describe the visibility of activities on the site to neighbors
What are the demographics of the community (socioeconomic level, ethnic composition, specific language
considerations, etc.)?
Local Interest
Has there been any media coverage?
Past Public Involvement
Has there been any past public interest in the site as reflected by community meetings, ad hoc committees, workshops,
fact sheets, newsletters, etc.?
DTSC 1381 (09/12/14)
page 3 of 4
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
SECTION 3
COMMUNITY INFORMATION (continued)
Key Issues and Concerns
Have any specific concerns/issues been raised by the community regarding past operations or present activities at the
site?
Are there any concerns/issues anticipated regarding site activities?
Are there any general environmental concerns/issues in the community relative to neighboring sites?
Key Contacts
Please attach a list of key contacts for this site, including city manager, city planning department, county environmental
health department, local elected officials, and any other community members interested in the site. Please include
addresses and phone numbers for each contact.
SECTION 4
CERTIFICATION
The signatory below is an authorized representative of the Project Proponent and certifies that the preceding
information is true to the best of their knowledge. The Applicant agrees to reimburse the lead agency (the Department
of Toxic Substances Control) for the lead agency’s costs in preparing and negotiating the appropriate cost recovery
agreement, regardless of whether the agreement is subsequently executed by the Applicant and the lead agency, and,
in the event the cost recovery agreement is executed by the parties, for oversight of the activities identified in the Scope
of Work of the selected Agreement.
Authorized Representative Name (Print)
Title
Signature
Date
Please forward the completed application and attachment(s) by mail, fax or in person to:
Ms. Ellen DelMar
Agreement Coordinator
Schools Team – Cypress
Department of Toxic Substances Control
5796 Corporate Avenue
Cypress, California 90630
Phone: (714) 484-5482
Fax: (714) 484-5326
Email:
edelmar@dtsc.ca.gov
Ms. DelMar will prepare and forward an agreement for review and signature. Subsequently, a project manager
will contact the identified principal contact for the proponent to schedule a scoping meeting.
DTSC 1381 (09/12/14)
page 4 of 4
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