Placer County, CA

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?*
1. Yes
2. 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:*
1. Less than one acre
2. 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*
1. Is not located in a Geographic Ultramafic Rock Unit area “most likely” to contain NOA (naturally occurring asbestos) as indicated by the CGS map.
2. 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.
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*
1. Commercial Property Development
2. Construction
3. Grading
4. Housing Development
1. Quarrying
2. Road Maintenance
3. Road or Railway Construction
1. Surface Mining
2. Trenching/Utilities Work
3. Other
Describe other:
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Control Measures

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.
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.<br><br> 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)
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*
1. 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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1. Receive an email copy of this form.
Email address

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Declaration: Project Is Not in a Naturally Occurring Asbestos (NOA) Area

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Control Methods for Active Storage Piles

Traffic Control for On-Site Unpaved Roads, Parking Lots & Staging Areas

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