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Dust Control Form
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Steps
1.
Contractor/Owner Information
This section is complete
This section is incomplete
2.
Project Description
This section is complete
This section is incomplete
3.
Control Measures
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This section is incomplete
4.
District Use Only
This section is complete
This section is incomplete
Contractor/Owner Information
Contractor Contact Information
Applicant Name
*
Applicant Company Name, if applicable
Address
*
City
*
State
*
Postal/Zip Code
*
Country
*
Applicant Email
*
Business Phone Number
*
Mobile Phone Number
Fax Number
Is there different contact information for the project Owner?
*
Yes
No
Owner Name
Company Name (if applicable)
Owner Address
City
State
Postal/Zip Code
Country
Owner Email
Business Phone Number
Mobile Phone Number
Fax Number
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Project Description
Assessor’s Parcel Number (APN)
Project Name
*
Name of approved environmental document/CUP for this project:
*
Project Number
Estimated Size of Project (total acres)
*
Disturbed Surface Area (acres):
*
The surface area to be disturbed is:
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Less than one acre
Greater than or equal to one acre
Brief Description of Project
*
Attach the Equipment List
Start Date
*
Start Date
Estimated Completion Date
*
Estimated Completion Date
Project Location
Location
*
Attach a sketch or map of the parcel location including the work area on the parcel:
*
Street Address
*
City
*
State
*
Zip
*
Country
*
Declaration: Project Is Not in a Naturally Occurring Asbestos (NOA) Area
We declare that the area to be disturbed during this project
*
Is not located in a Geographic Ultramafic Rock Unit area “most likely” to contain NOA (naturally occurring asbestos) as indicated by the CGS map.
Does not have naturally occurring asbestos, serpentine, or ultramafic rock as determined by the owner/operator, registered geologist, or the APCO.
Note:
If this declaration cannot be made, then an Asbestos Dust Mitigation Plan (ADMP) application is required in place of this Dust Control Plan. If NOA, serpentine or ultramafic rock is discovered in the area to be disturbed that is more than one acre after the start of any construction-related activity, an Asbestos Dust Mitigation Plan must be submitted to the District within 14 days of the discovery, along with implementation of subparagraphs 5.A. through 5.E. of the ADMP Guidance within 24 hours of the discovery.
Type
*
Commercial Property Development
Construction
Grading
Housing Development
Quarrying
Road Maintenance
Road or Railway Construction
Surface Mining
Trenching/Utilities Work
Other
Describe other:
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Control Measures
Track-out Prevention
Any visible track-out on a paved public road where vehicles enter and exit the work area must be removed at the end of the workday or at least once per day. Removal shall be accomplished by using wet sweeping or a HEPA filter equipped vacuum device. (Rule 228 Sections 304.1 and 304.2)
Select at least one additional control option that will be employed for track-out prevention:
*
A gravel pad designed using good engineering practices to clean the tires of exiting vehicles
A tire shake
A wheel wash system
Pavement extending for not less than 50 consecutive feet from the intersection with the paved public road
Any other measure(s) as effective as those listed
Describe any other measure(s)
Earth-Moving & Excavation Activities
Check to show your understanding of these requirements:
*
Visible Emissions not Allowed Beyond Boundary Line: A person shall not cause or allow the emissions of fugitive dust beyond the property boundary.
When wind speeds result in dust crossing the boundary line, grading and earthmoving operations shall be suspended, and inactive areas stabilized.
Dust shall not obstruct an observer’s view more than smoke that is as dark or darker in shade as than Number 2 on the Ringelmann Chart (40% opacity).
Application of water is required prior to any land clearing.
Select at least one control option for earth-moving activities:
*
Pre-wetting the ground to the depth of anticipated cuts
Reduction of earth moving equipment operational speed
Any other measure as effective as those listed
Other control measure:
Control Methods for Active Storage Piles
Check all that apply:
*
Keeping the surface adequately wet
Covering with tarps
Treating with a chemical dust suppressant
Any other control method that is equally effective
Describe other:
Traffic Control for On-Site Unpaved Roads, Parking Lots & Staging Areas
Check to show your understanding of these requirements
*
A maximum speed limit of 15 miles per hour (mph) unless the road surface and surrounding area is sufficiently stabilized to prevent violations.
If a local jurisdiction’s Ordinance is more restrictive than the above control measure, then the Ordinance must be adhered to.
Select at least one traffic control option:
*
Water every two hours during active operations or sufficiently often to keep the area adequately wet.
Apply chemical dust suppressants consistent with manufacturer’s directions.
Apply covering (please describe).
Any measure as effective as those listed.
Other measure:
Offsite Transport
Check to show your understanding of these requirements:
*
Vehicles leaving the site are cleaned to prevent dust, silt, mud and dirt from being released or tracked off site.
Trucks are maintained such that no spillage can occur from holes or other openings in cargo compartments.
Loads are adequately wet.
Select at least one offsite transport option:
Covered with tarps
Wetted and loaded such that material does not touch the front, back or sides of the cargo compartment at any point less than six inches from the top
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District Use Only
Monitoring
Sampling to determine compliance with the particulate concentration limit, of Rule 228 Section 303, is required only when deemed necessary by the Air Pollution Control Officer and requested, with reasonable notice. The person discharging emissions, or sampling may be conducted by the District with the costs of sampling borne by the person discharging the emissions. Sampling must be carried out according to Rule 228 Section 501.
Recordkeeping
Any contractor engaged in any active operation subject to this rule shall maintain records of the location, type of actions used to stabilize surface areas sufficiently and the date(s) of treatment.
Records shall be maintained and be readily accessible for two years after the date of each entry and shall be provided to the District upon request. Records shall be open for inspection during unscheduled audits during normal business hours. (Rule 228 Section 503.1). Results of any air sampling or air monitoring conducted at the request of the Air Pollution Control Officer shall be maintained for at least two years. (Rule 228 Section 503.2)
Construction Emissions/Equipment Inventory
If required as a Condition of Approval, a comprehensive equipment inventory list compliant with the Conditions of Approval shall be submitted 30 days prior to ground-breaking, with the inventory list updated beginning 30 days after any initial work has begun.
Comments
Attach Supporting Documents
Applicant Final Certification
*
I attest to the completeness of the Dust Control Plan entries, and that my company and all sub-contractors will comply with Rule 228, Fugitive Dust.
Once submitted changes are only available by contacting the District.
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