DTSC Form 1602 "Communication Assistance Resolution Form" - California

What Is DTSC Form 1602?

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 June 9, 2015;
  • 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 1602 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 1602 "Communication Assistance Resolution Form" - California

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Department of Toxic Substances Control
ATTN: Office of Civil Rights
th
1001 “I” Street, 11
Floor
Mathew Rodriquez
Edmund G. Brown Jr
Agency Secretary
Governor
P.O. Box 806
Cal/EPA
Sacramento, California 95812-0806
(916) 324-6546
The Department of Toxic Substances Control’s Language and
Communication Assistance Resolution Process
If you feel we have been unable to serve you because of language (limited-English
proficiency) or other communication differences, the Department may be able to
provide additional language or communication assistance that will assist with
accessing the information or services you have requested.
Please take the following steps to resolve your language or communication
assistance needs:
You may either contact the State Personnel Board at their toll free telephone
number (866) 889-3278 to leave a message or fill out the Communication
Assistance Resolution Form.
Be prepared to provide the following information:
1. Customer’s name (your name), address, and phone number or message
number.
2. Date service was sought and location of service.
3. The language in which you need service.
DTSC will attempt to resolve your concern within (10) business days.
DTSC 1602 (6/9/15)
Department of Toxic Substances Control
ATTN: Office of Civil Rights
th
1001 “I” Street, 11
Floor
Mathew Rodriquez
Edmund G. Brown Jr
Agency Secretary
Governor
P.O. Box 806
Cal/EPA
Sacramento, California 95812-0806
(916) 324-6546
The Department of Toxic Substances Control’s Language and
Communication Assistance Resolution Process
If you feel we have been unable to serve you because of language (limited-English
proficiency) or other communication differences, the Department may be able to
provide additional language or communication assistance that will assist with
accessing the information or services you have requested.
Please take the following steps to resolve your language or communication
assistance needs:
You may either contact the State Personnel Board at their toll free telephone
number (866) 889-3278 to leave a message or fill out the Communication
Assistance Resolution Form.
Be prepared to provide the following information:
1. Customer’s name (your name), address, and phone number or message
number.
2. Date service was sought and location of service.
3. The language in which you need service.
DTSC will attempt to resolve your concern within (10) business days.
DTSC 1602 (6/9/15)
Department of Toxic Substances Control
ATTN: Office of Civil Rights
Mathew Rodriquez
Edmund G. Brown Jr
th
1001 “I” Street, 11
Floor
Agency Secretary
Governor
Cal/EPA
P.O. Box 806
Sacramento, California 95812-0806
(916) 324-6546
COMMUNICATION ASSISTANCE RESOLUTION FORM
PLEASE USE SEPARATE FORM FOR EACH COMPLAINT
PERSON FILING COMPLAINT:
LOCATION/OFFICE WHERE INCIDENT OCCURRED:
PRIMARY LANGUAGE SPOKEN:
PERSON WITH WHOM YOU DEALT:
ADDRESS: (NUMBER AND STREET)
DATE AND TIME OF INCIDENT:
CITY, STATE AND ZIP:
TELEPHONE NUMBERS(S): (INCLUDE AREA CODE)
TELEPHONE NUMBER: (8AM-5PM, INCLUDE AREA CODE)
DO YOU WANT TO REMAIN ANONYMOUS?
YES
NO
EMAIL ADDRESS:
NOTE: IF YOU WISH TO REMAIN ANONYMOUS, WE MAY NOT BE
ABLE TO ADDRESS YOUR SPECIFIC ISSUE.
DESCRIBE YOUR COMPLAINT (Be specific-who, what, when, where, how):
Mail this completed form to the address listed on the top of this form. We will make efforts to
contact you within (10) business days of receiving this form.
Signature:
Date:
DTSC 1602 (6/9/15)
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