DTSC Form 1365 Disclosure Statement - Hazardous Waste Management Program - California

DTSC Form 1365 is a California Department of Toxic Substances Control form also known as the "Disclosure Statement - Hazardous Waste Management Program". The latest edition of the form was released in November 20, 2017 and is available for digital filing.

Download an up-to-date DTSC Form 1365 in PDF-format down below or look it up on the California Department of Toxic Substances Control Forms website.

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State of California
Department of Toxic Substances Control
California Environmental Protection Agency
8800 Cal Center Drive
Sacramento, California 95826
HAZARDOUS WASTE MANAGEMENT PROGRAM
DISCLOSURE STATEMENT
INSTRUCTIONS
Please read these instructions carefully. Applicants are required to comply with all applicable requirements. .
These instructions are intended to assist applicants in completing the Disclosure Statement (Form 1365),
which can also be found on the Department of Toxic Substances Control (DTSC) website. Please note
although the completed Disclosure Statement can be typed or printed legibly in ink; an original, signed copy
must be submitted to the Disclosure Statement Coordinator.
In answering questions applicants should remember the following:
You must complete all of the sections of the Disclosure Statement. If a section does not apply to you,
do not leave it blank. Instead write “Does Not Apply” in the section and include it with your Disclosure
Statement. Failure to respond to any portion of the Disclosure Statement will result in the Disclosure
Statement being rejected and returned to the applicant. Misrepresentations are subject to enforcement
action.
Make sure all of the pages included with the Disclosure Statement are numbered, including the total
number of pages. The page numbers are located at the bottom of each page.
The Declaration must be signed by an authorized person as follows:
Sole Proprietorship:
The individual who owns the business.
Partnerships:
The general or managing partner.
Corporations:
A Corporate officer authorized to make management decisions that govern the conduct of
hazardous waste activities.
Limited Liability Company:
A manager who is authorized to make management decisions that govern the conduct of
hazardous waste activities.
If you have any questions regarding completion of the Disclosure Statement, please contact the DTSC
Disclosure Statement Coordinator at the contact information provided in the renewal letter. A properly
completed Disclosure Statement will reduce the likelihood of delay in processing.
Page 1 of 9
DTSC 1365 Instructions (5/20/2015)
State of California
Department of Toxic Substances Control
California Environmental Protection Agency
8800 Cal Center Drive
Sacramento, California 95826
HAZARDOUS WASTE MANAGEMENT PROGRAM
DISCLOSURE STATEMENT
INSTRUCTIONS
Please read these instructions carefully. Applicants are required to comply with all applicable requirements. .
These instructions are intended to assist applicants in completing the Disclosure Statement (Form 1365),
which can also be found on the Department of Toxic Substances Control (DTSC) website. Please note
although the completed Disclosure Statement can be typed or printed legibly in ink; an original, signed copy
must be submitted to the Disclosure Statement Coordinator.
In answering questions applicants should remember the following:
You must complete all of the sections of the Disclosure Statement. If a section does not apply to you,
do not leave it blank. Instead write “Does Not Apply” in the section and include it with your Disclosure
Statement. Failure to respond to any portion of the Disclosure Statement will result in the Disclosure
Statement being rejected and returned to the applicant. Misrepresentations are subject to enforcement
action.
Make sure all of the pages included with the Disclosure Statement are numbered, including the total
number of pages. The page numbers are located at the bottom of each page.
The Declaration must be signed by an authorized person as follows:
Sole Proprietorship:
The individual who owns the business.
Partnerships:
The general or managing partner.
Corporations:
A Corporate officer authorized to make management decisions that govern the conduct of
hazardous waste activities.
Limited Liability Company:
A manager who is authorized to make management decisions that govern the conduct of
hazardous waste activities.
If you have any questions regarding completion of the Disclosure Statement, please contact the DTSC
Disclosure Statement Coordinator at the contact information provided in the renewal letter. A properly
completed Disclosure Statement will reduce the likelihood of delay in processing.
Page 1 of 9
DTSC 1365 Instructions (5/20/2015)
State of California
Department of Toxic Substances Control
California Environmental Protection Agency
8800 Cal Center Drive
Sacramento, California 95826
HAZARDOUS WASTE MANAGEMENT PROGRAM
DISCLOSURE STATEMENT
INSTRUCTIONS
INFORMATION PRACTICES NOTICE
The Disclosure Statement Form requires personal and confidential information.
(a) This information is required by the Hazardous Waste Management Program of DTSC which is within
the California Environmental Protection Agency.
(b) Maintenance of this information is the responsibility of:
Branch Chief
Permitting Division
Hazardous Waste Management Program
Department of Toxic Substances Control
8800 Cal Center Drive
Sacramento, California 95826-3200
(c) The requirement for submittal of the Disclosure Statement is authorized by California Health and Safety
Code sections 25112.5, 25169.5, 25200.4 and 25358.3.
(d) Submission of the requested personal and confidential information is mandatory, except as provided in
California Health and Safety Code section 25112.5(c) pertaining to a qualified corporation or subsidiary.
(e) Failure to provide complete information on the Disclosure Statement will likely result in delays in
processing and return of the incomplete forms for revision. Failure to provide statutorily required
information that is both complete and accurate may also result in denial of an application for a
hazardous waste facility permit or hazardous waste transporter registration and/or may result in
administrative, civil or criminal prosecution.
(f) The information in the Disclosure Statement is to be used principally for purposes of determining the
approval of an application for a hazardous waste facility permit, hazardous waste transporter
registration, or other hazardous waste facility grant of authorization.
(g) Personal and confidential information included on the Disclosure Statement will be released only to
appropriate agencies with law enforcement responsibility. No other persons may receive the
information without explicit statutory authority or a court order.
Individuals who are described in a Disclosure Statement will have a right to access personal information
pertinent to them in accordance with the California Information Practices Act, California Civil Code section
1798.34.
Page 2 of 9
DTSC 1365 Instructions (5/20/2015)
State of California
Department of Toxic Substances Control
California Environmental Protection Agency
8800 Cal Center Drive
Sacramento, California 95826
HAZARDOUS WASTE MANAGEMENT PROGRAM
DISCLOSURE STATEMENT
INSTRUCTIONS
Health and Safety Code section 25169.5 authorizes DTSC to receive criminal history summaries for the
purpose of performing background checks by the Department of Justice (DOJ) as part of the Disclosure
Statement requirement pursuant to Health and Safety Code section 25112.5. A Disclosure Statement cannot
be approved until DTSC has received DOJ clearance of fingerprint images and related identification
information on all individuals listed within the Disclosure Statement.
In order to meet this requirement, the following individuals listed within the Disclosure Statement must
complete both the fingerprint requirement and the background summary check:
(a) The sole proprietor;
(b) The partners;
(c) Any officers, directors, or partners, if the applicant is a business concern;
(d) All persons or any officers, partners, or any directors, if there are no officers, of a business concern
holding more than five percent of the equity in, or debt liability of the applicant (if the debt liability is held
by a lending institution, the applicant shall only supply the name and address of the lending institution).
NOTE: In some instances, individuals or businesses may be exempt from either the fingerprint and/or the
background summary requirements. To determine if you meet the exemption criteria, please refer to
Corporate Exemptions from Disclosure Statement and Fingerprint Requirements provided below.
FINGERPRINT IMAGES AND BACKGROUND CHECK REQUIREMENT
California Residents:
In order to complete the fingerprint/background check requirement, applicants residing in California can visit
any Applicant Live Scan satellite location where fingerprint images and related data are electronically
transmitted to DOJ. Applicant Live Scan information and fingerprint locations (including hours of operation and
costs related to live scan fingerprinting) can be obtained on the DOJ website at
www.caag.state.ca.us/fingerprints/index.htm.
Live Scan operators must verify the identity of the applicant prior to fingerprinting by requiring valid photo
identification. Examples of valid identification are a California driver license, valid out-of-state driver license,
California Department of Motor Vehicles ID card, military card, passport and alien registration
card/immigration/green card. Applicants are encouraged to contact the Live Scan location to determine if an
appointment for fingerprinting is recommended.
Following receipt by DOJ, the fingerprint images and background summaries are electronically processed by
the DOJ Networked AFIS Transaction Management System. Live Scan submissions, which have no data or
quality errors and do not result in possible criminal history matches, are processed automatically and DOJ will
provide an electronic response to a secured fax machine within DTSC’s Hazardous Waste Management
Program. DOJ will also coordinate other electronic processes resulting from the automated submissions of
fingerprints including forwarding the fingerprints to the FBI.
Applicants are to inform the Applicant Live Scan operator of ORI Code Number A0517, and Mail Code 09166,
which identifies DTSC as the agency to which DOJ will provide responses related to fingerprints and criminal
background summaries.
Page 3 of 9
DTSC 1365 Instructions (5/20/2015)
State of California
Department of Toxic Substances Control
California Environmental Protection Agency
8800 Cal Center Drive
Sacramento, California 95826
HAZARDOUS WASTE MANAGEMENT PROGRAM
DISCLOSURE STATEMENT
INSTRUCTIONS
Other States:
For applicants residing in states other than California, “rolled” fingerprint cards will need to be submitted to
DOJ and the FBI. In order to obtain needed fingerprint cards
(Form
FD-258), please visit California’s
Department of Justice, Office of the Attorney General, at http://oag.ca.gov/fingerprints/security. Each applicant
will be required to submit two fingerprint cards (one for DOJ and one for the FBI). Please note that a check,
made payable to the Department of Justice in the amount of $49.00 is required for each applicant submitting
fingerprint cards (see the
Applicant Fingerprint Processing Fees chart
for more information).
NOTE: Due to the large volume of Live Scan requests/fingerprint cards (Form FD-258) being submitted
to DOJ and the FBI, it can take as long as 90 days for DTSC to receive background clearance results
from both of these agencies. It is also not unusual for an individual’s fingerprints to be rejected by
DOJ and/or the FBI due to the quality of fingerprint characteristics. If this occurs, DTSC will notify the
applicant by telephone to request that Live Scan or fingerprint cards be resubmitted. It generally takes
30 to 60 days for DTSC to receive results from DOJ and/or the FBI on resubmitted fingerprint cards.
Guidelines for DTSC Use and Storage of Fingerprints/Background Checks
In order to review the contents of a facility or transporter Disclosure Statement, all applicable DTSC employees
have been fingerprinted and received criminal background clearance by the Department of Justice. In addition,
DOJ mandates that DTSC employees having access to information related to fingerprint analysis and
background criminal checks be trained.
DOJ also requires that, prior to receiving documentation related to fingerprints/background criminal histories,
that HWMP identify a locked office with a fax machine designated for use by DOJ to electronically transmit
information. This secured office, which is locked at all times, contains all facility and transporter Disclosure
Statements files.
CORPORATE EXEMPTIONS FOR SUBMITTAL OF DISCLOSURE STATEMENT AND FINGERPRINT
REQUIREMENTS
Some corporations are exempt from submitting the Disclosure Statement and/or from the fingerprint/criminal
background summary requirements. Public corporations that are listed by the Securities and Exchange
Commission (SEC) or are wholly owned subsidiaries of a SEC listed company are exempt from the
requirement to submit fingerprints. To also be exempt from the Disclosure Statement requirement, a
corporation must have operated a hazardous waste facility or interim status facility in California as of
January 1, 1984.
Corporations claiming these exemptions must still report all missing hazardous wastes of concern and must
meet all of the requirements of Health and Safety Code section 25112.5(b) and (c). If a company believes that
it qualifies for these exemptions, it is required to submit a letter to DTSC providing an explanation of its
exemption eligibility.
Page 4 of 9
DTSC 1365 Instructions (5/20/2015)
State of California
Department of Toxic Substances Control
California Environmental Protection Agency
8800 Cal Center Drive
Sacramento, California 95826
HAZARDOUS WASTE MANAGEMENT PROGRAM
DISCLOSURE STATEMENT
INSTRUCTIONS
The following corporations are exempt from one or both of these requirements:
(a) A corporation, the stock of which is listed on a national securities exchange and registered under the
Securities Exchange Act of 1934 (Title 15 of the United States Code sec. 78a et seq.) or a subsidiary of
such a corporation, is not subject to the fingerprint requirement of Health and Safety Code section
25112.5(a).
(b) Corporations with stock listed on a national securities exchange or on the National Market System of the
NASDAQ Stock Market and registered under the Securities Exchange Act of 1934 (15 U.S.C. Sec. 78a et
seq.) or a subsidiary of that corporation, in lieu of submitting a Disclosure Statement, may submit to DTSC
copies of all period reports, including, but not limited to, those reports required by section 78m of Title 15 of
the United States Code and Part 229 (commencing with section 229.10) of Chapter II of Title 17 of the
Code of Federal Regulations that the corporation or subsidiary has filed with the Securities and Exchange
Commission the three years immediately preceding the submittal. This exemption only applies if the
corporation or subsidiary has held a hazardous waste facilities permit or operated a hazardous
waste facility under interim status in California as of January 1, 1984, pursuant to section 25200 or
25200.5.
Page 5 of 9
DTSC 1365 Instructions (5/20/2015)

Download DTSC Form 1365 Disclosure Statement - Hazardous Waste Management Program - California

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