Los Altos, CA · Santa Clara County
PCBs Screening Assessment Form
This form screens proposed demolitions for PCBs requirements and is completed by the property owner or representative and the consultant, when applicable.
What this form is
Submit this form with a demolition permit application. All applicants complete Parts 1, 2, and 4; applicants whose projects meet the screening criteria also complete Part 3 and its tables. The form requests owner, consultant, and project details, screening answers, and, when required, PCBs concentration results and supporting sampling records.
Who needs it
Applicants submitting a demolition permit application complete this form, with Part 3 information required for projects that meet the screening criteria.
How to submit it
Submit the completed form with your demolition permit application. The form does not provide a submission address, email, portal, or fee information.
About notarization
No notary is required; the property owner or representative and consultant sign and date, and the form identifies no notarized or sworn attachment.
How to submit this form
- 1
Download the Form
Download the PCBs Screening Assessment Form for your demolition permit application.
- 2
Complete the Applicable Parts
Fill in Parts 1, 2, and 4. Use your Part 2 answers to determine whether Part 3 and its tables apply.
- 3
Gather Supporting Records
If completing Part 3, include the supporting reports, checklist, and analytical data required for your sampling option.
- 4
Submit With Your Permit Application
Submit the completed form with your demolition permit application.
Frequently asked questions
- Do I need a notary for the PCBs Screening Assessment Form?
- No. The form has signature and date lines for the property owner or representative and the consultant, but does not require notarization or identify a notarized or sworn attachment.
- 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, portal, or fee.
- Which parts of the form must applicants complete?
- All applicants complete Parts 1, 2, and 4. Complete Part 3 and its tables if the answers in Part 2 indicate the project meets the screening criteria.
- What supporting information may Part 3 require?
- For representative sampling, provide a contractor’s assessment report, a QA/QC checklist, and analytical data reports. For existing sampling records, provide a contractor’s report or statement and analytical data reports.