C
G
S
ALIFORNIA
EOLOGICAL
URVEY
D
C
E P A R T M E N T
O F
O N S E R V A T I O N
APPLICATION
FOR ASSESSMENT OF GEOLOGIC HAZARD REPORTS
CGS Form 1A (08/11)
For CGS use only
CGS project number___________
Date received _______________
In order for CGS to review geologic hazard reports for a proposed school project, as described on Division of the State
Architect (DSA) Interpretation of Regulations IR-4 (see ), the following
material must be submitted to CGS:
this form, which will help CGS and the DSA coordinate reviews;
TWO SIGNED COPIES of the Work Order (attached below), signed by an authorized representative of the District;
a check for $3600 to cover the time and materials needed for CGS review;
Geologic Hazard Reports to be reviewed - ONE copy of each report.
Submit Reports to:
California Geological Survey
School Review Unit
801 K Street, MS 12-32
Sacramento, CA 95814-3531
Name of School:
School District or State Agency:
Mailing Address:
District Superintendent:
Telephone Number:
E-mail Address:
District Director of Facilities:
Telephone Number:
E-mail Address:
Scope of Work:
Applicable Building Code (year):
Community College Project per:
DSA-SS, or
DSA-SS/CC amendments
This project includes a site-specific ground motion analysis in accordance with:
none
ASCE 7
ASCE 41
Project location (Street Address):
City and Zip Code:
County:
APN:
Project Funding Status (Category 1, 2, 3, or 4; per Form DSA-10)
Funding Deadline (if Cat. 4):
Project Tracking Number (PTN):
DSA Application Number (if assigned):