Dublin, CA · Alameda County
PCBs Screening Assessment Form
Property owners or their agents and consultants complete this form to screen a building proposed for demolition and submit it with the demolition permit application.
What this form is
This form screens a building proposed for demolition for PCBs in priority building materials and records owner, consultant, project, and building information. All applicants complete Parts 1, 2, and 4; Part 3 applies when the screening answers indicate an applicable structure and complete demolition. When Part 3 applies, applicants report material concentrations and provide supporting sampling records.
Who needs it
Property owners or their agents and consultants submit this form with a demolition permit application for a building proposed for demolition.
How to submit it
Submit the completed form with your demolition permit application. The form does not provide a submission address, email, or portal.
About notarization
This document is signed and dated without a notary; when Part 3 applies, attach contractor documentation and analytical data reports, plus a QA/QC checklist for representative sampling.
How to submit this form
- 1
Download The Form
Download the PCBs Screening Assessment Form.
- 2
Complete The Applicable Parts
Complete Parts 1, 2, and 4. Follow the screening answers to determine whether Part 3 applies.
- 3
Gather Supporting Records
If Part 3 applies, include the required contractor documentation and analytical data reports; representative sampling also requires a QA/QC checklist.
- 4
Submit With Your Permit Application
Submit the completed form with your demolition permit application.
Frequently asked questions
- What is the PCBs Screening Assessment Form?
- It screens a building proposed for demolition for PCBs in priority building materials and collects owner, consultant, project, and building details.
- Who completes the PCBs Screening Assessment Form?
- Property owners or their agents and consultants complete the form. All applicants fill out Parts 1, 2, and 4; Part 3 applies when the screening answers require it.
- Do I need a notary for the PCBs Screening Assessment Form?
- No. The form has signature and date lines but no notary block. Signers complete those lines; if Part 3 applies, include the required contractor documentation and analytical data reports, with a QA/QC checklist for representative sampling.
- How do I submit the PCBs Screening Assessment Form?
- Submit the completed form with your demolition permit application. The form does not list a submission address, email, or portal.
Need something notarized?
This PCBs Screening Assessment Form doesn’t need a notary — but if you have another Dublin form that does, a commissioned online notary can help.