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ALIFORNIA ENVIRONMENTAL PROTECTIONAGENCY • <br /> DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br /> SITE MITIGATION STATEWIDE CLEANUP OPERATIONS <br /> VOLUNTARY CLEANUP PROGRAM APPLICATION <br /> The purpose of this application is to obtain information necessary to determine the eligibility of the site for <br /> acceptance into the Voluntary Cleanup Program. Please use additional pages, as necessary, to complete your <br /> responses. <br /> SECTION 1 PROPONENT INFORMATION <br /> Proponent Name <br /> Principal Contact Name <br /> Phone ( ) <br /> Address <br /> Proponent's relationship to site <br /> Brief statement of why the proponent is interested in DTSC services related to site <br /> SECTION 2 SITE INFORMATION <br /> Is this site listed on Calsites? ❑ Yes ❑ No <br /> If Yes, provide specific name and number as listed <br /> Name of Site <br /> Address City County ZIP <br /> (Please attach a copy of an appropriate map page) <br /> DTSC 1254 (3/95) A-1 <br />