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Home My WebLink Aboutprelimreview-service-request-application Alameda County Department of Environmental Health Local Oversight Program 1131 Harbor Bay Pkwy, Alameda, CA 94502 Phone: 510-567-6700 Fax: 510-337-9335 Web: https://deh.acgov.org/landwater/lop.page Service Request Application – Preliminary Site Review OFFICE USE ONLY Date Rec’d: Rec’d By: Amt $: PE Code: RO#: GT ID#: SERVICE REQUEST TYPE & MINIMUM FEE DEPOSIT SERVICE SERVICE SERVICE REQUEST TYPEFEEPE CODESERVICE REQUEST TYPEFEE PE CODE CODE CODE APPLICATION PROCESSING FEE CONSULTATION MEETING $174 5504 312 $696 5502 707 (1 HOUR) (TWO STAFF, 2 HOUR STAFF TIME)  REVIEW ENVIRONMENTAL & PROJECT $522 5502 311 $1,392 TOTAL FEES DUE DOCUMENTS & DATABASES (3 HOURS STAFF TIME) Indicated fees are due upon application submittal. Fees can be paid via cash, credit card, check or money order. Please return this application to ACDEH in person, or by mail at 1131 Harbor Bay Parkway, Ste 111, Alameda CA, 94502. S ITE A DDRESS - For Multiple Addresses/APNs use Address Form on Page 6 Alameda County Assessor’s Parcel Numbers (APNs) list all: Street: City: State: Zip Code: P ROPERTY O WNER I NFORMATION Property Owner Name: Type of Entity: Individual, Corporation, Trust, etc. Mailing Address ( same as site address) Street: City: State: Zip Code: Phone: Email: R ESPONSIBLE P ARTY E NTERING A GREEMENT Name: Relationship to Property Owner: Mailing Address Street: City: State: Zip Code: Phone: Email: A FFIDAVIT  I attest under penalty of perjury to the truth and correction of all the facts, exhibits, reports, and attachments presented with and made a part of this request.  Responsible Party and Current Property Owner represent that the Responsible Party has the authority to make this request for preliminary site review.  I agree to pay all fees and costs associated with receiving the necessary approvals for my project. Property Owner Signature: Date: Responsible Party’s Signature: Date: OFFICE USE ONLY Application Completeness Review: LOP Staff Signature: ________________________________________________________________ Date: ____________ Refund Amount: $___________ LOP PM Signature: ________________________________________________________________ Date: ____________ prelimreview-service-request-application.docx Page 1 of 6 Alameda County Department of Environmental Health Local Oversight Program 1131 Harbor Bay Pkwy, Alameda, CA 94502 Phone: 510-567-6700 Fax: 510-337-9335 Web: https://deh.acgov.org/landwater/lop.page Service Request Application – Preliminary Site Review Initiating Action for Service Request (CHECK APPLICABLE BOX) E NVIRONMENTAL D UE D ILIGENCE Property Transaction  Self-Initiated Site Assessment  Bank Re-Financing Other_________________________________ P ROPERTY R EDEVELOPMENT Planning/Building Department Clearance Other____________________________________ Site Information Summary Type and Extent of Contamination by APN and list all Associated Environmental Documents: Identify history of site and substances found at site. prelimreview-service-request-application.docx Page 2 of 6 Alameda County Department of Environmental Health Local Oversight Program 1131 Harbor Bay Pkwy, Alameda, CA 94502 Phone: 510-567-6700 Fax: 510-337-9335 Web: https://deh.acgov.org/landwater/lop.page Service Request Application – Preliminary Site Review Project Description Summary Planned Redevelopment/Project Description: Provide brief description of type of planned redevelopment and the what prompted the need for Preliminary Site Review. Include a discussion of the entitlement process status and applicable planning and building department permit numbers and approvals. prelimreview-service-request-application.docx Page 3 of 6 Alameda County Department of Environmental Health Local Oversight Program 1131 Harbor Bay Pkwy, Alameda, CA 94502 Phone: 510-567-6700 Fax: 510-337-9335 Web: https://deh.acgov.org/landwater/lop.page Service Request Application – Preliminary Site Review Required Documents The Responsible Party shall submit to ACDEH all background information, environmental assessment reports (including Phase I/II Environmental Assessment Reports), analytical results, and if redevelopment is proposed, additional documents as listed below. If select documents are not available or applicable, please provide an explanation in the text box below. All available information is to be provided to ACDEH by the Responsible Party with this completed application. ACDEH will review the application and contact the Responsible Party within five (5) days of receipt to schedule a meeting. SUBMIT THE FOLLOWING WITH THIS APPLICATION AND FEES. Environmental Due Diligence (for all Sites) Site Development Package ☒ Parcel Map/ Site Map ☒ Planning Department Permit #_________________ 1 ☒ Legal Description ☒ Entitlement Approvals or Conceptual Development Plan ☒ Phase I Reports ☒ CEQA Documents ☒ Phase II Reports ☒ Subdivision Parcel Maps ☒ Geophysical Survey Reports ☒ Building Permit #__________________________ ☒ Geotechnical Reports ☒ Building Plan Set ☒ Summary Figures illustrating all parcel boundaries, ☒ Grading Plans including Cut/Fill Balance and historic, current and proposed site ☒ Utility Plans configurations in relation to sampling locations ☒ Demolition Plans including Lead, Asbestos, and PCB ☒ Summary Tables of all Analytical Data Abatement Documentation ☒ Boring Logs ☒ Property Transactions and Proposed Project ☒ Aerial Photos Development Schedule ☒ Sanborn Maps 1 Legal description is the geographical description of a real estate property for identifying and locating the property. A legal description of the property clearly identifies the location, boundaries, and any existing easements of the property. Legal description is available on the deed. List Not Applicable or Unavailable Documents prelimreview-service-request-application.docx Page 4 of 6 Alameda County Department of Environmental Health Local Oversight Program 1131 Harbor Bay Pkwy, Alameda, CA 94502 Phone: 510-567-6700 Fax: 510-337-9335 Web: https://deh.acgov.org/landwater/lop.page Service Request Application – Preliminary Site Review Application Instructions To initiate regulatory review on a project, complete and submit this Service Request Application, review fee and required documents. Fill in all blanks. Submit the completed application form including required documents in PDF format to: Paresh Khatri Alameda County Department of Environmental Health 1131 Harbor Bay Parkway Alameda, CA 94502 (email preferred: paresh.khatri@acgov.org). Submit the associated fees to: Alameda County Department of Environmental Health c/o Finance Department 1131 Harbor Bay Parkway Alameda, CA 94502-6577 (Fees can be paid via cash, credit card, check or money order in-person) This deposit will be applied towards work performed for opening an account, preliminary site review time by Alameda County Department of Environmental Health (ACDEH) staff, inter-agency coordination, and an in-person meeting with you and your environmental professional. An application processing fee of $174 will be charged for processing each Service Request Application. Incomplete applications (missing key information and/or supporting documents) will be rejected by ACDEH and will be assessed an additional re-submittal processing fee of $174.00. Once the application has been accepted and fees received, an Identification Number will be established in the State Water Board’s GeoTracker website (http://geotracker.waterboards.ca.gov/). ACDEH will upload all technical reports/submittals to GeoTracker. ACDEH will conduct an initial screening of the application for completeness and will contact the applicant within five (5) business days to schedule a meeting or provide notification of an incomplete application requiring resubmittal. Once ACDEH deems the application is complete, ACDEH will review the submitted information to determine whether regulatory environmental oversight is required. If it is determined that regulatory oversight is required, ACDEH will consult with the Regional Water Board or Department of Toxic Substances Control staff to determine lead agency status. prelimreview-service-request-application.docx Page 5 of 6 Alameda County Department of Environmental Health Local Oversight Program 1131 Harbor Bay Pkwy, Alameda, CA 94502 Phone: 510-567-6700 Fax: 510-337-9335 Web: https://deh.acgov.org/landwater/lop.page Service Request Application – Preliminary Site Review Multiple Addresses / APNs Form Site Addresses SITE ADDRESS: (Street, City, Zip) Associated APN: SITE ADDRESS: (Street, City, Zip) Associated APN: SITE ADDRESS: (Street, City, Zip) Associated APN: SITE ADDRESS: (Street, City, Zip) Associated APN: SITE ADDRESS: (Street, City, Zip) Associated APN: SITE ADDRESS: (Street, City, Zip) Associated APN: SITE ADDRESS: (Street, City, Zip) Associated APN: prelimreview-service-request-application.docx Page 6 of 6