HomeMy WebLinkAboutHazardous Waste Signature 4-15-20 (Signed) CITY OF 5^141
E LA K LSINO E
HAZARDOUS WASTE SITE
PLANNING DIVISION & PUBLIC WELL SITE INFORMATION
Government Code Section 65962.5,which became effective July 1, 1987, requires the applicant for any
development project to consult specified state-prepared lists of hazardous waste sites and submit a
signed statement to the local agency indicating whether the project is located on or near an identified
site. Under the statute, no application shall be accepted without the signed statement.
PART A
To determine if your project is on or near an identified Hazardous Waste Site please refer to any State
identified Hazardous Waste Sites as listed by the County of Riverside Department of Environmental
Health.
Is the project located on or near a State identified Hazardous Waste Site? Yes❑ No
(If you answered yes to the above question, please fill out the information below. If you answered no,
please sign and date the certification below).
Name of Applicant: Danny Singh
3017 E. Edinger Ave.
Address Tustin, CA 92780
Phone Number 949-630-5345
NWC Mountain Street and Lake Street
Address of Site Lake Elsinore, CA 92530
Local Agency(City/County) Lake Elsinore City/Riverside County
389-030-012,013,014,015,016,017,018
APN(s)
Specify any list pursuant to
Section 65962.5 of the
Government Code
Regulatory ID Number
Date of List
PART B
To determine if your project is within one(1) mile radius of a public well site,which could potentially be
affected by a hazardous waste generator, please refer to the State identified Public Well Sites.
Is your project within a one-mile radius of an identified public well? Yes❑ No
If yes, please identify:
CERTIFICATION
I hereby certify that the statements furnished above and in the attached exhibits present the data
and information required for this initial evaluation to the best of my ability, and that the facts,
statements,and information presented are true and correct to the best of my knowledge.
SIGNATURE: DATE: 04/16/20