Please submit completed application no later than Friday, January 4, 2013

Por favor, de completar su solicitud y envíe a más tardar el viernes 4 de enero de 2013.

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Application for Membership on the Community Advisory Group SSFL

Members of the Santa Susana Field Laboratory (SSFL) community intend to establish a Community Advisory Group (CAG) for the SSFL Project. The Department of Toxic Substances Control (DTSC) is assisting the community in forming this CAG after receiving a petition signed by more than 50 people. About the Santa Susana Field Laboratory The Santa Susana Field Laboratory (SSFL) is located 30 miles northwest of downtown Los Angeles in southeastern Ventura County, near the crest of the Simi Hills at the western border of the San Fernando Valley. A former rocket engine test and nuclear research facility, the 2,849-acre field laboratory is currently the focus of a comprehensive environmental investigation and cleanup program, conducted by Boeing, the United States Department of Energy (DOE) and the National Aeronautics and Space Administration (NASA), and overseen by the Department of Toxic Substances Control. Conditions for Membership Members serving on a CAG are volunteers who attend CAG meetings and participate in the duties of a CAG. Duties and responsibilities will include listening to presentations from technical teams and other experts, reviewing and commenting on technical documents and developing recommendations to share with DTSC which reflect opinions of members of the communities the CAG represents. Members will be expected to facilitate the exchange of information and/or concerns between the community they represent and DTSC. SSFL CAG members can expect to devote a minimum of 12 days per year to participate in SSFL CAG activities. SSFL CAG membership must be reflective of the diversity and interests of the community surrounding the SSFL Project site. Please answer the following questions.
First Name	Last Name
Street Address	City
State	Zip Code
Daytime Phone	Evening Phone
Email
1. Briefly, state why you would like to participate in the SSFL CAG.
2. Describe a recent experience where you worked as a member of a diverse group with common goals.
3. One of the responsibilities of the SSFL CAG is to communicate information to others in the community. As a member of the SSFL CAG, how would you accomplish this goal?
4. The SSFL CAG will be composed of representatives from the following list. Please indicate the category that you feel best represent and provide a description:
Property owner or resident of property located near the SSFL Project or in an adjacent community.
Local business community.
Local political or government agency.
Member of a local citizen, civic, environmental, or public interest group residing in the County.
Other
Do you participate in other local groups where people are interested in the SSFL Project?
Please feel free to provide DTSC with your concerns on the CAG or other issues related to the SSFL Project.

Thank you for completing this application Please submit your completed application no later than Friday, January 4, 2013 to: For additional information or questions regarding the SSFL CAG or the SSFL Project, please contactMarina Perez, Public Participation Specialist, at (818) 717-6569, or visit our website at: www.dtsc.ca.gov/SiteCleanup/Santa_Susana_Field_Lab. If you would like more information about Community Advisory Groups, visit our Web site at www.dtsc.ca.gov/GetInvolved/upload/PP_Guidance_CAG.pdf.

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