HomeMy WebLinkAbout6. Hazardous Waste-Well Site Information (1)
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 identifies Hazardous Waste Sites as listed on CalEPA’s Cortese List Data Resources.
Is the project located on or near a State identifies 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:
Address:
Phone Number:
Address of Site:
Local Agency (City/County)
APN(s)
Specific 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 hazardous waste generator, please refer to State identified Public Well
Sites.
Is your project within a one-mile radius of an identified public well? Yes ☐ No ☐
If yes, please identify: ____________________________________________________________
Hazardous Waste Site & Public Well
Site Information
4
4
Plugged Well 1 (API 0406500093), Plugged Well 2 (API 0406500132)
Docusign Envelope ID: 374FDAA2-0E08-4BF0-8558-3C626A1B7F57
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: _________________
Docusign Envelope ID: 374FDAA2-0E08-4BF0-8558-3C626A1B7F57
8/8/2024