"Prospective Purchaser Application Form" - California

Prospective Purchaser Application 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 June 1, 1996;
  • 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 "Prospective Purchaser Application Form" - California

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CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
DEPARTMENT OF TOXIC SUBSTANCES CONTROL
SITE MITIGATION STATEWIDE CLEANUP OPERATIONS
PROSPECTIVE PURCHASER APPLICATION
PP Application
NO.
Region
-
-
f i - - - -
The purpose of this application is t o obtain information necessary t o evaluate the eligibility of applicants
for the Prospective Purchaser Agreement Program. Please use additional pages, as necessary, t o
complete your responses.
SECTION 1
APPLICANT INFORMATION
Page
1
DTSC 6/96
1
Applicant Name
Mailing Address
City, State, ZIP
Phone Number
Contact for Project
Mailing Address
City, State, ZIP
Phone Number
Current Site Owner
If owner is a corporation or business, provide name of person representing owner for this site.
Mailing Address
City, State, ZIP
Phone Number
Purchaser Information
(May arrach buvness
card here)
Is the current owner aware of your plans to seek a Prospective Purchaser Agreement
with
DTSC?
Yes
NO
Are you planning to purchase the property?
Yes
No
If
Yes,
when do you expect to take title to the property?
If
No,
what is your proposed interest in the property and what vehicle will be
used to consummate the transaction?
Please describe, if known, the timing of the proposed property transaction in
sufficient detail to give
DTSC
a
sense of your needs and timetable.
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CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
DEPARTMENT OF TOXIC SUBSTANCES CONTROL
SITE MITIGATION STATEWIDE CLEANUP OPERATIONS
PROSPECTIVE PURCHASER APPLICATION
PP Application
NO.
Region
-
-
f i - - - -
The purpose of this application is t o obtain information necessary t o evaluate the eligibility of applicants
for the Prospective Purchaser Agreement Program. Please use additional pages, as necessary, t o
complete your responses.
SECTION 1
APPLICANT INFORMATION
Page
1
DTSC 6/96
1
Applicant Name
Mailing Address
City, State, ZIP
Phone Number
Contact for Project
Mailing Address
City, State, ZIP
Phone Number
Current Site Owner
If owner is a corporation or business, provide name of person representing owner for this site.
Mailing Address
City, State, ZIP
Phone Number
Purchaser Information
(May arrach buvness
card here)
Is the current owner aware of your plans to seek a Prospective Purchaser Agreement
with
DTSC?
Yes
NO
Are you planning to purchase the property?
Yes
No
If
Yes,
when do you expect to take title to the property?
If
No,
what is your proposed interest in the property and what vehicle will be
used to consummate the transaction?
Please describe, if known, the timing of the proposed property transaction in
sufficient detail to give
DTSC
a
sense of your needs and timetable.
Print
Reset Form
SECTION
2
SITE INFORMATION
-
i
Site Name
DTSC Name and Number (if applicable)
Street Address/Physical Location
City, County, State
Assessor's Parcel Number
Zoning Designation and Land Uses
Surrounding Land Uses (within %-mile)
Legal Description and Title Report
Attach copy of map of site and legal boundary description
Attach copy of Title Report
*
Nature of t h e Hazardous Substance Release
Br~efly descr~be the nature of the hazardous substance release at the property.
Have chemicals been found in:
Soil
Groundwater
Surface Water
Is hazardous waste treatment, storage or disposal occurring at the site?
Yes
No
Attach a copy of the Preliminary Endangerment Assessment or Phase 1 / 1 1 Environmental Assessment Reports
Present Land Uses
Is the site currently being used?
Yes
No
If Yes, describe the nature of the current use.
1
Page
2
- - -
DTSC 6/96
SECTION 3
SCOPE OF WORK FOR REUSE AND REMOVAL OR REMEDIAL ACTIVITIES
Describe the proposed development or reuse of the property. If available, you may attach site maps
and supplemental information describing the intended development or reuse.
Provide a brief summary of removal or remedial activities which have been undertaken or completed
at the property already, if any.
Briefly describe, in general terms, the removal or remedial activities t o be performed in the future.
If the applicant or current owner has been or is subject t o an order or agreement w i t h DTSC, provide
the name of the DTSC project manager(s) and phone number(s).
DTSC Project Manaaer(s1
Phone Nurnberlsl
Responsible
Parties
0
Attach a list of names and addresses of potentially responsible parties.
Describe all efforts t o identify the potentially responsible parties.
Page
3
DTSC 6/96
T
Benefit to the Community
-
Describe the "substantial benefit" t o the State of California which will result if your proposal is
implemented. For example, describe the number of jobs created, number of homes built, amount of
commercial/industriaI space created, acreage remediated and returned t o use, and changes expected
.
in the local and state tax base. Describe other benefits t o the community and surrounding
neighborhood which could occur as a result of this project.
Other Agency Involvement
List names, addresses and phone numbers of the agencies and individuals contacted t o determine if
other agencies have taken actions at this site.
Agency
Contact
Phone
Are other agencies currently taking actions concerning the site?
Yes
No
If Yes, name the agency, and describe the action, timing and result
Agency
Action
Timing
Result
Financial Assurance
Describe the method of financial assurance t o complete remediation prior t o development of the site.
_I
-
Page
4
DTSC 6/96
J
I
Post-Remedial Certification Activities
If remediation is occurring during and after construction, such as groundwater treatment or soil vapor
extraction, a separate Operation and Maintenance Agreement must be finalized t o assure that
remedial activities occur until remedial goals are met.
SECTION 4
SIGNATURE AND
CERTIFICATION
Persons signing this application certify that they are authorized t o submit an application and begin
negotiation process by the applicants. The applicants and their undersigned representatives are not now
nor have been in the past a responsible party or affiliated w i t h a responsible party for this site.
Signature below affirms this statement under penalty of perjury.
Submission of this application indicates that the applicant is willing t o enter into an agreement with
DTSC and is willing t o pay DTSC oversight costs for implementation of the agreement as well as costs
associated w i t h negotiating the agreement.
PLEASE NOTE THAT DTSC STAFF WILL CONTACT YOU IF FURTHER INFORMATION IS NEEDED TO PROCESS YOUR
APPLICATION.
Appn;cant Signature
Date
Title
DTSC 6/96
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