Heating Oil Technical Assistance Program (HOTAP) Application & Agreement - eSignature


PART 1 - ADMINISTRATION

A. Customer Information

Name of Customer:    

What type of entity is the Customer?:    

If person, Customer Mailing Address:    

If person, Customer Phone:    

If person, Customer Email:    

What is the Customer's involvement at the Site?       

If not the current property owner, is the Customer acting as the agent for the property owner?    

If not the current property owner, is the Customer authorized to grant access to the property?    

B. Project Manager Information

Name:    

Title:    

Mailing Address:    

Phone:    

Fax:    

Email:    

C. Project Consultant Information

Is the Customer a consultant?:    

If no, Consultant Name:    

If no, Consultant Title:    

If no, Consultant Mailing Address:    

If no, Consultant Phone:    

If no, Consultant Fax:    

If no, Consultant Email:    

Do you want PLIA to contact the Project Consultant?:    

D. Project Owner Information

Is the Customer the owner of the property where independent remedial action is being conducted?:    

If yes, what type of entity is the property owner?:        

If no, Property Owner Name:    

If no, Property Owner Address:    

If no, Property Owner Phone:    

If no, Property Owner Fax:    

If no, Property Owner Email:    

If no, what type of entity is the property owner?:       

PART 2 - DESCRIPTION OF THE SITE

A. Location of Property where the Releases Occurred (Source Property)

Do you know on which property the releases occurred?:   

NOTE: If you answered YES to the above, then the following refers to the source property. If you answered NO, then the following refers to the property addressed by your remedial action (cleanup). 

Physical Address:    

TAX PARCEL #(S):    

B. Identification of Properties affected by the Releases (Affected Properties)

Do any of the releases affect any properties adjacent to the source property?:    

If yes, Address 1:    

Tax Parcel(s):    

If yes, Address 2:    

Tax Parcel(s):    

If yes, Address 3:    

Tax Parcel(s):    

If yes, Address 4:    

Tax Parcel(s):    

(Additional properties may be attached as additional pages using the file upload area of the online form.)

C. Identification of Public Right-of-Ways affected by the Releases

Do any of the releases affect any public right-of-ways (e.g., streets)?:    

If yes, please specify:    

D. Description of Release(s) at the Site

Source of Release(s). To the extent known, please describe the source(s) of the release(s):    

Circumstances of Release(s). To the extent known, please describe below the circumstances of the release(s):    

Circumstances of Release Discovery. To the extent known, please describe below the circumstances of the discovery of the release(s):    

(Additional information may be attached using the file upload area of the online form.)

Drinking Water

Does any of the contamination at the Site pose a threat or potential threat to an existing drinking water source (ground water or surface water)?:    

If yes, what type of drinking water system is threatened by the contamination?:    

Is the contamination located within or upstream of a 10-year wellhead protection area?:   

Indoor Air

Are contaminant odors present in any buildings, manholes, or other confined spaces?:    

If yes, please specify:    

E. Maps of the Site

(Maps are submitted using the file upload area of the online form.)

PART 3 - OPERATIONAL HISTORY OF THE SITE

A. Future Use of Source and Affected Properties

Will any ownership interest in the source or affected properties be conveyed prior to, or upon completion of, the cleanup?:    

If yes, please specify:    

Will any of the source or affected properties, or portions of those properties, be redeveloped as part of the cleanup?:    

If yes, please specify the proposed land use:      

If yes, please also specify the activities proposed for that land use:    

(Additional information may be attached using the file upload area of the online form.)

PART 4 - ADMINISTRATIVE HISTORY OF THE SITE

Have you previously reported the release(s) of hazardous substances at the Site to PLIA?:    

If so, when?:    

Has the cleanup of the Site, or any portion of the Site, ever been managed under the HOTAP?:    

If so, please specify the HOTAP Project Number:    

PART 5 - DESCRIPTION OF INDEPENDENT REMEDIAL ACTIONS AT THE SITE

A. Scope of Remedial Actions

Do you plan to characterize and address all of the contamination at the Site, including any contamination located on affected adjacent properties, as part of the HOTAP project?:    

If no, please describe below the scope of the HOTAP project, including the contamination (properties, portions of a property, media and/or hazardous substances) that you DO NOT plan on characterizing and/or addressing as part of the HOTAP project:    

(Additional information may be attached using the file upload area of the online form.)

B. Status of Remedial Actions

INITIAL RESPONSE (UST ONLY):    

INTERIM ACTION:    

REMEDIAL INVESTIGATION:    

FEASIBILITY STUDY:    

CLEANUP ACTION:    

C. Documentation of Remedial Actions

Remedial Actions:

 

PART 6 - TERMS OF AGREEMENT

 

Acceptance of Terms of Agreement:

 

PART 7 - STATEMENT AND SIGNATURE

A. Statement

The undersigned affirms that the information contained in this application is true and accurate to the best of his or her knowledge.

The undersigned affirms that he or she understands and agrees to to the terms of the Agreement for the Washington State Heating Oil Assistance Program (HOTAP) as listed in the printed version of the online form. 

Name:    

Title:    

Organization:    

Mailing Address:    

Phone:    

Fax:    

Email:    

B. Affiliation

What is the signatory’s involvement at the Site?:      

 

File Uploads

 

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Signature Certificate
Document name: Heating Oil Technical Assistance Program (HOTAP) Application & Agreement - eSignature
lock iconUnique Document ID: 1f47361ab94202b27573a794099adde2a42052fc
Timestamp Audit
2017-01-22 21:35:15 PSTHeating Oil Technical Assistance Program (HOTAP) Application & Agreement - eSignature Uploaded by PLIA Admin - pliamail@plia.wa.gov IP 75.189.139.34