\\admin\PNShare\_ PLANNING FORMS\_MASTER COPY PDF 2 of 2
(REV 02.17.22)
Generally, Zoning Permits and Residential Administrative Permits will not require the completion of the following sec-
tions: “Hazardous Site Review Statement”, “Hazardous Materials Disclosure Statement”, or “Military Land Use Compat-
ibility”, as part of this Application Form. These sections must be completed for all applications that require
Planning Commission and/or Board of Supervisors approval.
I/We, the applicant, certify that the following responses are true and correct. Yes No
HAZARDOUS MATERIALS DISCLOSURE STATEMENT
Government Code Section 65850.2 requires the owner or authorized agent for any development project to disclose
whether:
1. Compliance will be needed with the applicable requirements of Section 25505 and Article 2 (commencing with Sec-
tion 25531) of Chapter 6.95 of Division 20 of the Health and Safety Code or the requirements for a permit for con-
struction or modification from the air pollution control district or air quality management district exercising jurisdiction
in the area governed by the County.
Yes No
2. The proposed proj
ect wil
l have more than a threshold quantity of regulated substance in a process or will contain a
source or modified source of hazardous air emissions.
Yes No
MILITARY LAND USE COMPATIBILITY
Using the California Military Land Use Compatibility Analyst website, the owner or authorized agent has determined
whether the project is located within 1,000 feet of a military installation, beneath a low-level flight path or within special
use airspace as defined in Section 21098 of the Public Resources Code, and within an urbanized area as defined by
Government Code Section 65944.
Yes No
BY SIGNING THIS APPLICATION, THE APPLICANT/PROPERTY OWNER AGREES TO DEFEND, INDEMNIFY, AND HOLD THE
COUNTY HARMLESS FROM ANY CLAIM, ACTION, OR PROCEEDING BROUGHT TO ATTACK, SET ASIDE, VOID, OR ANNUL
THE COUNTY’S APPROVAL OF THIS APPLICATION AND ENVIRONMENTAL REVIEW ASSOCIATED WITH THE PROPOSED
PROJECT, AS MORE FULLY DESCRIBED IN CHAPTER 1.18 OF THE SHASTA COUNTY CODE.
APPLICANT/AGENT: I have reviewed this application and attached material. The information provided is accurate.
If other than the owner, this signature must be accompanied by a Shasta County notorized statement of agency form
.
Signed:________________________________________________________ Date:________________________
PROPERTY OWNER: I have read this application and consent to its filing. THIS SIGNATURE IS REQUIRED
Signed:________________________________________________________ Date:________________________
HAZARDOUS SITE REVIEW STATEMENT
Government Code Section 65962.5 (f) requires the applicant for any development project to consult specified state-
prepared lists and submit a signed statement to the local agency indicating whether the project is located on an identified
site. Under the statue, no application can be accepted as complete without this signed statement.
I/We certify that I/We have investigated this development project with respect to the Cal EPA’s Cortese List Data Re-
sources webpage and that my/our answers are true and correct to the best of my/our knowledge. My/Our investigation
has shown that:
The project is NOT located on any of the lists compiled pursuant to Section 65962.(e) of the Government Code.
The project IS located on one of the lists compiled pursuant to Section 65962.(e) of the Government Code. Please
specify the list, the date of the list, and the property’s regulatory identification number:
___________________________________________________________________________________