Form CEM-1904 "Agreement Between a Contractor Working on State Facilities and a Real Property Owner for Disposing Construction Related Material on Commercial Zoned Property Owner's Property" - California

What Is Form CEM-1904?

This is a legal form that was released by the California Department of Transportation - 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 December 1, 2018;
  • The latest edition provided by the California Department of Transportation;
  • 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 Form CEM-1904 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

ADVERTISEMENT
ADVERTISEMENT

Download Form CEM-1904 "Agreement Between a Contractor Working on State Facilities and a Real Property Owner for Disposing Construction Related Material on Commercial Zoned Property Owner's Property" - California

Download PDF

Fill PDF online

Rate (4.7 / 5) 19 votes
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
AGREEMENT BETWEEN A CONTRACTOR WORKING ON STATE FACILITIES AND A REAL
PROPERTY OWNER FOR DISPOSING CONSTRUCTION RELATED MATERIAL ON COMMERCIAL
ZONED PROPERTY OWNER'S PROPERTY
CEM-1904 (NEW 12/2018)
Page 1 of 2
CONTRACT NUMBER
COUNTY/ROUTE/POST MILES
The contractor,
(Contractor), has entered into Contract
Number
(Contract), with the State of California, Department of Transportation (Department),
for work that is described as follows:
The owner,
(Owner), of the real property (Property)
located at
(for example, address, location, county and parcel number(s), project station(s), offsets, and other property location information) agrees to
allow the Contractor to dispose on the Owner's Property approximately
cubic yards of
(such as soil, aggregate, asphalt grindings, or other material), hereafter referred to as “Material,” generated from the Project.
The Owner agrees that the Contractor has assumed ownership from the Department of the Material that is being disposed on the Property.
Owner acknowledges the material being deposited on the Property contains lead with concentrations between 80 mg/kg and 320 mg/kg which
is above the residential California Human Health Screening Level for Lead as determined by California Environmental Protection Agency
(CalEPA). By submission of this agreement, the Owner certifies 1) the Property is a commercial/industrial property and 2) the Property is not
and will not be used for any type of housing, including but not limited to, apartment, motel, hotel, farm, ranch, or any other type of property,
including but not limited to, daycare, park, school, hospital, university, which could allow occupants to reside on the property now or in the
future or would lead to daily, repeated, long term exposure to the material. The Property is zoned as
.
Owner acknowledges receipt of a copy of the information handout containing lead concentration data.
The Contractor and Owner agree to abide by the requirements of Section 5-1.20, “Coordination with Other Entities,” of the Standard
Specifications. The Standard Specifications are available at:
http://www.dot.ca.gov/hq/esc/oe/standards.php
The Contractor and Owner agree to obtain and furnish to the Department's resident engineer, all necessary permits, licenses, agreements,
certifications, and clearances prior to placing Material on the Property.
By submission of this agreement to the Department's resident engineer, the Contractor and Owner are acknowledging that they have been
informed, or otherwise apprised, of all restrictions, laws, and permit requirements associated with the transporting and placement of the
Material on the Property and have agreed to abide by the same. These laws include but are not limited to:
• Local Ordinances — Grading permits for the grading, filling, excavation, storage, or disposal of soil or earthen material.
• California Fish and Game Code (Section 1602), “Lake or Stream Bed Alteration Agreement” — A permit required prior to the
removal or placement of material in a location where it can pass into waters of the state, directly or indirectly, through causes such as
erosion or maintenance.
• California Fish and Game Code (Section 5650) — A prohibition against the deposition of petroleum products (including asphalt), or
any material deleterious to fish, plants, or birds where it can pass into the waters of the state.
• Federal Clean Water Act (Sections 301 and 402), “General Permit for Discharges of Storm Water Associated with Construction
Activity” — A permit is required prior to soil disturbance of an area of one acre or more.
• Federal Clean Water Act (Section 404), “Permit for Discharge of Dredged or Fill Material” — A permit from the United States Army
Corps of Engineers may be required for the discharge of fill material into waters of the United States including wetlands.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
AGREEMENT BETWEEN A CONTRACTOR WORKING ON STATE FACILITIES AND A REAL
PROPERTY OWNER FOR DISPOSING CONSTRUCTION RELATED MATERIAL ON COMMERCIAL
ZONED PROPERTY OWNER'S PROPERTY
CEM-1904 (NEW 12/2018)
Page 1 of 2
CONTRACT NUMBER
COUNTY/ROUTE/POST MILES
The contractor,
(Contractor), has entered into Contract
Number
(Contract), with the State of California, Department of Transportation (Department),
for work that is described as follows:
The owner,
(Owner), of the real property (Property)
located at
(for example, address, location, county and parcel number(s), project station(s), offsets, and other property location information) agrees to
allow the Contractor to dispose on the Owner's Property approximately
cubic yards of
(such as soil, aggregate, asphalt grindings, or other material), hereafter referred to as “Material,” generated from the Project.
The Owner agrees that the Contractor has assumed ownership from the Department of the Material that is being disposed on the Property.
Owner acknowledges the material being deposited on the Property contains lead with concentrations between 80 mg/kg and 320 mg/kg which
is above the residential California Human Health Screening Level for Lead as determined by California Environmental Protection Agency
(CalEPA). By submission of this agreement, the Owner certifies 1) the Property is a commercial/industrial property and 2) the Property is not
and will not be used for any type of housing, including but not limited to, apartment, motel, hotel, farm, ranch, or any other type of property,
including but not limited to, daycare, park, school, hospital, university, which could allow occupants to reside on the property now or in the
future or would lead to daily, repeated, long term exposure to the material. The Property is zoned as
.
Owner acknowledges receipt of a copy of the information handout containing lead concentration data.
The Contractor and Owner agree to abide by the requirements of Section 5-1.20, “Coordination with Other Entities,” of the Standard
Specifications. The Standard Specifications are available at:
http://www.dot.ca.gov/hq/esc/oe/standards.php
The Contractor and Owner agree to obtain and furnish to the Department's resident engineer, all necessary permits, licenses, agreements,
certifications, and clearances prior to placing Material on the Property.
By submission of this agreement to the Department's resident engineer, the Contractor and Owner are acknowledging that they have been
informed, or otherwise apprised, of all restrictions, laws, and permit requirements associated with the transporting and placement of the
Material on the Property and have agreed to abide by the same. These laws include but are not limited to:
• Local Ordinances — Grading permits for the grading, filling, excavation, storage, or disposal of soil or earthen material.
• California Fish and Game Code (Section 1602), “Lake or Stream Bed Alteration Agreement” — A permit required prior to the
removal or placement of material in a location where it can pass into waters of the state, directly or indirectly, through causes such as
erosion or maintenance.
• California Fish and Game Code (Section 5650) — A prohibition against the deposition of petroleum products (including asphalt), or
any material deleterious to fish, plants, or birds where it can pass into the waters of the state.
• Federal Clean Water Act (Sections 301 and 402), “General Permit for Discharges of Storm Water Associated with Construction
Activity” — A permit is required prior to soil disturbance of an area of one acre or more.
• Federal Clean Water Act (Section 404), “Permit for Discharge of Dredged or Fill Material” — A permit from the United States Army
Corps of Engineers may be required for the discharge of fill material into waters of the United States including wetlands.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
AGREEMENT BETWEEN A CONTRACTOR WORKING ON STATE FACILITIES AND A REAL
PROPERTY OWNER FOR DISPOSING CONSTRUCTION RELATED MATERIAL ON COMMERCIAL
ZONED PROPERTY OWNER'S PROPERTY
CEM-1904 (NEW 12/2018)
Page 2 of 2
The Owner and Contractor agree that the Material will be transported, deposited, and left in a manner that will not cause injury or harm to any
person or property. If an injury or harm does occur to any person or property or should any environmental impacts or litigation arise as a result
of the excavation, removal, transportation, deposition, or the final form in which the Property is left, the Contractor, agrees to indemnify,
defend, protect, and hold harmless the Department in any action in law or equity in accordance with Section 7-1.05, “Indemnification,” of the
Standard Specifications regardless of the manner or form of the action.
Pursuant to Section 5-1.20B(4), “Contractor-Property Owner Agreement,” of the Standard Specifications, the Owner acknowledges that the
Contractor will submit this agreement to the Department as evidence that the Owner has authorized the placement of the Material on the
Property. The Owner acknowledges that the Contractor is not authorized to make any representations or agreements on behalf of the
Department. The Contractor and Owner agree that the Department is released from any and all obligations to the Owner made by Contractor
under this agreement and the Department is released from any and all obligations to the Owner under any prior agreement made between the
Department and Owner.
The Owner and Contractor acknowledge that they have had the opportunity to receive independent legal advice with respect to the meaning,
implications, and advisability of entering into and executing this agreement.
PROPERTY OWNER (Print Name)
SIGNATURE
DATE
CONTRACTOR'S AUTHORIZATION REPRESENTATIVE PER STANDARD SPECIFICATIONS Section 5-1.16
REPRESENTATIVE (Print Name)
SIGNATURE
DATE
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Page of 2