225 Camino Del Remedio Santa Barbara, CA 93110805/681-4900 FAX 805/681-4901

Environmental Health Services

225 Camino del RemedioSanta Barbara, CA 93110805/681-4900FAX 805/681-4901

2125 S. Centerpointe Pkwy. #333Santa Maria, CA 93455-1340805/346-8460FAX 805/346-8485

Lawrence Fay Director of Environmental Health

Environmental Hazardous Materials Services

Voluntary Remediation Oversight Program Application

The purpose of this application is to obtain information necessary to determine a contaminated site's eligibility for acceptance into the Santa Barbara County Public health Department (PHD) Voluntary Remediation Oversight Program (VROP). Please use additional pages, as necessary, to complete your responses.

SECTION 1 — RESPONSIBLE PARTY INFORMATION

Responsible Party Contact:

Name:

Address:

Phone no.:

Email:

Authorized Representative:

Name:

Address:

Phone no.:

Email:

Site Address:

Brief statement of why the responsible party is interested in having PHD oversee

the remediation of this site:

SECTION 2 — SITE INFORMATION

Is this site listed on EnviroStor? Yes No

If yes, provide specific name and number as listed:

Name of Site:

EnviroStor ID#:

Site Address:Street

CityState Zip

Assessor Parcel No(s).

(Please attach a copy of an appropriate Assessor Parcel map page)

Current Owner

Name:

Address:

Phone :

Email:

Background: Previous Business Operation

Name

Type

Years of Operation

If known, list all previous businesses operating on this property.

Name

Type

Years of Operation

Name

Type

Years of Operation

What hazardous substances/wastes have been associated with this site?

What environmental media is/was/may be contaminated? Please check all that apply.

SoilSoil VaporIndoor AirOutdoor Air

Groundwater Surface Water

Has sampling or other investigation been conducted? Yes No

If yes, specify:

If yes, what hazardous substances have been detected and what were their maximum concentrations? Attach a data summary table(s) if more space is needed.

Are any Federal, State or Local regulatory agencies currently involved with this site?

Yes No

If yes, state the involvement, and give contact names and telephone numbers.

Agency / Involvement / Contact Name / Phone

Is this site the subject of an enforcement action or consent order? If yes please describe.

What is the proposed future use of this site?

What oversight service is being requested of the PHD? (check all that apply)

Phase II Site Assessment Preliminary Endangerment Assessment

Remedial Investigation/Feasibility Study Removal action

Remedial Action Remedial Action Plan Certification

Other (describe the proposed project)

Is there currently a potential for the community or workers to be exposed to hazardous substances at this site? Yes No

If yes, explain:

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SECTION 3 – COMMUNITY PROFILE INFORMATION

Describe the site property (include approximate size)

Describe the surrounding land use (including proximity to residential housing, schools, churches etc.)

What are the demographics of the community (e.g., socioeconomic level, ethnic composition, specific language considerations, etc.)?

Has there been any past public interest in this site as reflected by community meetings, ad hoc committees, workshops, fact sheets, newsletters, etc.?Please attach copies of available documents, meeting minutes, etc.

Please specify:

Please list any specific concerns/issues that have been raised by the community regarding past operations or present activities at this site, any anticipated concerns/issues regarding site activities, or general environmental concerns relative to neighboring sites?

Please attach a list of key contacts for this site, including: County/City Planning Department, County Environmental Health Department, local elected officials, and any other community members interested in the site. Include phone numbers, e-mail and regular mail addresses.

SECTION 4 – CERTIFICATION

The Responsible Party certifies that the preceding information is true to the best of their knowledge.

______Date