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Home My WebLink Aboutsoil-import-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 – Soil Import/Export Characterization Soil Import_Service_Request_Application_2019-11-13 Rev 3 Page 1 of 4 OFFICE USE ONLY SERVICE REQUEST TYPE & MINIMUM FEE DEPOSIT (CHECK ALL THAT APPLY) SERVICE REQUEST TYPE FEE PE CODE SERVICE SERVICE REQUEST TYPE FEE PE CODE SERVICE  APPLICATION PROCESSING FEE $174 5502 312  FILL MATERIAL CHARACTERIZATION $522 5502 311  INTERAGENCY COORDINATION $348 5502 311 SOIL IMPORT MANAGEMENT PLAN $522 5502 311  CONSULTATION MEETING TWO STAFF HR STAFF TIME $696 5502 707 OIL VALUATION LEARANCE ETTER HOURS STAFF TIME $348 5502 313  SITE VISIT $870 5502 105 OIL VALUATION LEARANCE $348 5502 313 TOTAL MINIMUM FEES:$1,218.00  LEGAL DOCUMENT $174/ HR 5502 232 Minimum fees are checked. Additional fees may be required to complete review. 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. FILL DESTINATION SITE ADDRESS Alameda County Assessor’s Parcel Number (APN): Street: City: State: Zip Code: PROPERTY OWNER INFORMATION Property Owner Name: Mailing Address ( same as property address) Phone: Email: OWNER’S REPRESENTATIVE  Mailing Address Street: City: State: Zip Code: Phone: Email: AFFIDAVIT  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 Soil Import/Export Clearance.  I agree to pay all fees and costs associated with receiving the necessary approvals for my project. OFFICE USE ONLY Application Completeness Review: LOP Staff Signature: ________________________________________________________________ Date: ____________ Refund Amount: $___________ LOP PM Signature: ________________________________________________________________ Date: ____________ 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 – Soil Import/Export Characterization Soil Import_Service_Request_Application_2019-11-13 Rev 3 Page 2 of 4 Initiating Action for Service Request  N/A  Existing Soil Import Clearance Evaluation  Proposed Soil Import Clearance Evaluation REGULATORY AGENCY INITIATED SERVICE REQUEST  N/A Note: This section should only be filled out if you have been contacted by ACDEH regarding one the categories below.  Alameda County Public Works Agency (PWA) Referral to ACDEH – Violation of AC Grading Ordinance – Stop Work Order  Alameda County Community Development Agency (CDA) Referral to ACDEH  CDA Referral to ACDEH – Soil Import Clearance (Proposed & Existing Soil)  CDA Referral to ACDEH - Site Development Review  Other Regulatory Agency Referral to ACDEH Provide a brief project description: Include purpose, quantity, location, and dimensions of soil to be imported and/or location of existing imported soil. 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 – Soil Import/Export Characterization Soil Import_Service_Request_Application_2019-11-13 Rev 3 Page 3 of 4 Site Description Describe current site conditions, including current land use, topography, existence of ecological receptors (e.g. streams, creeks, lakes, etc.). and existence of structures or proposed structures. Attach Site Map with 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 – Soil Import/Export Characterization Soil Import_Service_Request_Application_2019-11-13 Rev 3 Page 4 of 4 Application Instructions Please note, all project applications are subject to a 10-business day processing period before being placed in ACDEH’s permitting queue. To initiate regulatory oversight on a project, complete and submit pages one through three of this Service Request Application. Fill in all blanks. If a particular item does not apply to your project, check the not applicable box. Submit the completed application form and send it 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 ACDEH staff, inter-agency coordination, and an in-person meeting with you and your environmental professional. Additional fees may be required to complete the evaluation and provide clearance for fill import, as listed in the Service Request Type / Minimum Fee Deposit Schedule listed on Page 1 of this application. If it is determined that contaminated fill has been brought to the site, you will be required to enter into a Voluntary Remedial Action Agreement (VRAA) under ACDEH’s Site Cleanup Program (SCP) for further site characterization, remediation, and/or mitigation. Once the application has been accepted, a Case Number will be established in the State Water Board’s GeoTracker website (http://geotracker.waterboards.ca.gov/). All technical reports/submittals must be uploaded in pdf format to GeoTracker. 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 may be assessed an additional re-submittal processing fee of $174.00.