DTSC Form 1195 "Community Involvement Profile" - California

What Is DTSC Form 1195?

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 March 1, 2019;
  • 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 fillable version of DTSC Form 1195 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 1195 "Community Involvement Profile" - California

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CLEAR
State of California – California Environmental Protection Agency
PRINT
Department of Toxic Substances Control
COMMUNITY INVOLVEMENT PROFILE
Please type or print legibly in ink
COMMUNITY PROFILE FOR (Facility Name): _______________________________________________
EPA I.D. # ______________________________
DATE: _________________________________
This community involvement profile (Profile) must be submitted with the permit application pursuant to California Code
of Regulations, title 22, section 66270.14(b)(23). The Profile only needs to include reasonably available information for
the surrounding community. For purposes of the Profile, the surrounding community must include the U.S. census tract
in which the facility is located. If the facility is located in a census tract that has a population of fewer than 2,000 people,
any other census tracts located within one (1) mile of the facility must also be included.
Section A: Project Description.
Provide a description of the proposed hazardous waste facility that includes all the following:
1. List the activities to be conducted by the owner or operator that require a hazardous waste facility permit
as specified in Cal. Code Regs., tit. 22, § 66270.13(a) and § 66270.13(i).
2. List the hazardous waste facility site address or, if a street address is not available, an equivalent
description of the facility’s location.
3. List the county assessor’s parcel number(s) or a description of the legal boundaries of the facility
site as required by Cal. Code Regs., tit. 22, § 66270.14(b)(18)(G).
4. List the surrounding land uses and zoning designations within 2,000 feet of the facility’s
boundaries as specified in Cal. Code Regs., tit. 22, § 66270.14(b)(18)(D).
DTSC 1195 (03/01/19) Revision to comply with Cal. Code Regs., tit. 22, § 66270.14(b)(23)
Page 1 of 6
CLEAR
State of California – California Environmental Protection Agency
PRINT
Department of Toxic Substances Control
COMMUNITY INVOLVEMENT PROFILE
Please type or print legibly in ink
COMMUNITY PROFILE FOR (Facility Name): _______________________________________________
EPA I.D. # ______________________________
DATE: _________________________________
This community involvement profile (Profile) must be submitted with the permit application pursuant to California Code
of Regulations, title 22, section 66270.14(b)(23). The Profile only needs to include reasonably available information for
the surrounding community. For purposes of the Profile, the surrounding community must include the U.S. census tract
in which the facility is located. If the facility is located in a census tract that has a population of fewer than 2,000 people,
any other census tracts located within one (1) mile of the facility must also be included.
Section A: Project Description.
Provide a description of the proposed hazardous waste facility that includes all the following:
1. List the activities to be conducted by the owner or operator that require a hazardous waste facility permit
as specified in Cal. Code Regs., tit. 22, § 66270.13(a) and § 66270.13(i).
2. List the hazardous waste facility site address or, if a street address is not available, an equivalent
description of the facility’s location.
3. List the county assessor’s parcel number(s) or a description of the legal boundaries of the facility
site as required by Cal. Code Regs., tit. 22, § 66270.14(b)(18)(G).
4. List the surrounding land uses and zoning designations within 2,000 feet of the facility’s
boundaries as specified in Cal. Code Regs., tit. 22, § 66270.14(b)(18)(D).
DTSC 1195 (03/01/19) Revision to comply with Cal. Code Regs., tit. 22, § 66270.14(b)(23)
Page 1 of 6
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Section B: Surrounding Community Demographics.
Provide a preliminary identification and summary of the following relevant demographic characteristics as defined by the U.S.
Census Bureau regarding the surrounding community for the most current year. (Information can be found at
https://oehha.ca.gov/calenviroscreen
or, for existing facilities, on the CalEnviroScreen tab on the facility’s EnviroStor page).
1. Age structure:
2. Educational attainment:
3. Household income:
4. Languages spoken in the home:
5. Linguistic isolation or ability to speak English:
6. Population size, and population projections, if available:
7. Race and ethnicity data:
8. Unemployment rate:
Section C: Surrounding Community Issues.
Identify known health or environmental concerns relevant to the facility’s operation, hazardous waste activities, or facility
modifications that have been asserted by the public or government agencies since the last hazardous waste facility permit
issuance date.
DTSC 1195 (03/01/19) Revision to comply with Cal. Code Regs., tit. 22, § 66270.14(b)(23)
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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Section D: Surrounding Community Interest.
Summarize or describe any known public activities, such as public meetings or hearings, regarding the hazardous waste facility
within the last five (5) years.
Section E: Sensitive Receptors.
Identify sensitive receptors in the surrounding community.
1. Schools:
2. Child care facilities:
3. Hospitals:
4. Elderly housing:
5. Elder care facilities:
6. Convalescent facilities:
7. Other:
DTSC 1195 (03/01/19) Revision to comply with Cal. Code Regs., tit. 22, § 66270.14(b)(23)
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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Section F: Location of Tribal Lands.
Identify tribal lands in the surrounding community that are owned either by an individual Native American or a Tribe, the title to
which is held in trust by the federal government or a Native American Tribe located in California that is on the contact list
maintained by the Native American Heritage Commission for the purposes of Chapter 905 of the Statutes of 2004.
Section G: Potential Off-Site Sources.
Identify and provide the locations of any potential off-site handlers of hazardous materials or hazardous waste within the
surrounding community.
1. Other hazardous waste facilities:
2. Large-quantity generators of hazardous waste:
3. Sites identified by the Department pursuant to Health and Safety Code section 65962.5 Hazardous
Waste and Substances Sites (Cortese) List:
DTSC 1195 (03/01/19) Revision to comply with Cal. Code Regs., tit. 22, § 66270.14(b)(23)
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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
4. Entities or industrial facilities required to report under the Toxics Release Inventory Program pursuant to
the federal Emergency Planning and Community Right-to-Know Act (EPCRA), section 313. (42 U.S.C.
§11023 and 40 CFR Part 372):
5. Entities or industrial facilities handling or storing any hazardous material that are required to report under
section 312 of EPCRA. (42 U.S.C. §11022 and 40 CFR Part 355):
6. Transportation corridors in relation to the facility, including freeways, major state vehicle routes,
seaports, airports, and railyards:
Section H: Community Groups (e.g., neighborhood council)
Identify informal groups, local organizations or other coordinated efforts known to be interested in this project:
DTSC 1195 (03/01/19) Revision to comply with Cal. Code Regs., tit. 22, § 66270.14(b)(23)
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