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Voluntary Cleanup Program <br /> Washington State Department of Ecology <br /> DEPARTMENT OF <br /> ECOLOGY Toxics Cleanup Program <br /> State of Washington <br /> APPLICATION FORM <br /> Under the Voluntary Cleanup Program (VCP), the Department of Ecology (Ecology) may provide informal <br /> site-specific technical consultations to persons conducting independent remedial actions at a hazardous <br /> waste site. Ecology may provide such consultations under the authority of the Model Toxics Control Act <br /> (MTCA), Chapter 70.105D RCW, and its implementing regulations, Chapter 173-340 WAC. <br /> To enter the VCP, complete and submit to Ecology a VCP Application. The Application consists of the <br /> following two documents: <br /> 1. Application Form (including required attachments). 4- THIS DOCUMENT <br /> 2. Agreement. <br /> For guidance on how to complete your Application, please refer to the Application Instructions, which are <br /> available separately on the VCP web site: www.ecy.wa.qov/programs/tcp/vcp/vcpmain.htm. <br /> Part 1 -ADMINISTRATION <br /> A. Customer Information. The Customer is the person or organization requesting services from <br /> Ecology under the VCP, and is responsible for paying the costs incurred by Ecology. The authority and <br /> duty of the Customer are explained in the Agreement. <br /> Name of Customer: City of Everett <br /> What type of entity is the Customer? <br /> If the Customer is a "person," then the Customer shall serve as both <br /> ❑ Person the Project Manager and the Project Billing Contact. Please identify <br /> this person and their contact information in both Parts 1B and 1C. <br /> If the Customer is an "organization,"then please identify the Project <br /> ® Organization Manager in Part 1B and the Project Billing Contact in Part 1C. Both <br /> persons must be employed by the Customer organization. <br /> What is the Customer's involvement at the Site? Please check all that apply. <br /> ® Property owner ❑ Business owner (operator) <br /> ❑ Past property owner Mortgage holder <br /> ❑ Future property owner ❑ Consultant <br /> Property lessee ❑ Attorney <br /> 7 Other— please specify: <br /> If not the current property owner, is the Customer acting as the agent for the property owner? <br /> ❑ Yes ❑ No <br /> If not the current property owner, is the Customer authorized to grant access to the property? <br /> ❑ Yes j No <br /> ECY 020-74(revised May 2013) 1 <br />