RECORD OF SITE CLOSURE (REMEDIAL ACTION OR CORRECTIVE ACTION) State Form (10-10) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Transcription

1 RECORD OF SITE CLOSURE (REMEDIAL ACTION OR CORRECTIVE ACTION) State Form (10-10) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 1. SITE INFORMATION INSTRUCTIONS: 1. The purpose of this form is to clarify expectations and achieve consistency in investigations, reporting and decision-making for sites addressed under the remediation programs of the Indiana Department of Environmental Management (IDEM.) Information in this form should be an executive summary of the Remedial Action or Corrective Action. 2. Complete and submit this form with a Closure Report when you have implemented a Remediation Work Plan (RWP) or Corrective Action Plan (CAP), and seek closure approval from IDEM 3. You may complete this form electronically, however a paper copy of this form and all attachments should accompany the Closure Report. 4. You may include additional information on separate sheets where needed. 5. Note: If there was a Record of Remedy Selection, Sections 8, 9 and 10 of this form should contain only new information. See the instructions for each of these sections. 6. All instructions within this form are in italics. a. Name b. Date (mm, dd, yyyy) c. RWP or CAP Amendment number d. IDEM site/incident/fid number e. Location f. IDEM Remediation Section Leaking Underground Storage Tanks (LUST) Excess Liability Trust Fund (ELTF) Voluntary Remediation (VRP) State Cleanup (SC) Brownfields Program (BF) 2. RESPONSIBLE PARTY/ PARTICIPANT INFORMATION a. Name b. Address (number and street, City, State, ZIP code) 3. CONSULTANT INFORMATION a. Name b. Address (number and street, City, State, ZIP code) c. Telephone number d. address 4. SITE DESCRIPTION a. Site type (type of industry or release) and size of affected area (acres). The nature and extent of contamination exceeding residential remediation goals as determined in accordance with the most recent revision of the Risk Integrated System of Closure (RISC) Technical Guide is considered to be the affected area. b. Current and expected land use of the affected area. (Check all that apply). Residential Commercial/Industrial Recreational c. Current and expected land use adjacent to the affected area. (Check all that apply). Residential Commercial/Industrial Recreational d. Contaminant types. (Check all that apply based on your Conceptual Site Model (CSM)). Metals Volatile Organic Compounds Semi Volatile Organic Compounds PCBs Petroleum Pesticides/Herbicides Other (describe) e. Contaminated media. (Check all that apply based on your CSM). Surface soil Subsurface soil Air Indoor air(vapor intrusion) Surface water Ground water Sediment Other (describe) f. Is any part of the affected area within a Well Head Protection Area? Yes No RECORD OF SITE CLOSURE Page 1 of 6

2 5. SUMMARY OF COMPLETED REMEDIATION OR CORRECTIVE ACTION Briefly describe completed remediation or corrective action, including risk management approaches, and basis for the associated remediation objective. In accordance with Indiana Code (IC) (d), remediation may be based on any one or more than one of the following: (1) Remediation based on background levels of hazardous substances and petroleum that occur naturally on the site; or (2) Remediation based on an assessment of the risks. Risk based remediation shall be based on one (1) of the following: (a) Levels of hazardous substances and petroleum calculated by the department using standard equations and default values for particular hazardous substances or petroleum; (b) Levels of hazardous substances and petroleum calculated using site specific data for the default values in the department's standard equations; or (c) Levels of hazardous substances and petroleum developed based on site specific risk assessments that take into account site specific factors, including remedial measures, restrictive covenants, and environmental restrictive ordinances that: (A) manage risk; and (B) control completed or potential exposure pathways. (See Section 6.a.) i. Basis for remediation for each contaminant (Group contaminants if addressed by the same type of remediation objective). ii. Potential exposure pathway addressed Background. Contaminant(s) Risk-based, standard equations, default values. Contaminant(s) Risk-based, site specific data for default values in standard equations. Contaminant(s) Risk-based, site specific factors; including remediation measures. Contaminant(s) iii. Remediation measures, including risk management approaches 6. BASIS FOR CLOSURE a. Type of closure: (Check the correct statement). Closure is unconditional. Closure is conditional. b. Unconditional closure. (If unconditional closure, select and briefly explain why unconditional closure is appropriate then proceed to Section 9. Provide the title of the report where detailed information may be located, and the location of the pertinent information within that report (e.g. page, section, table, or figure number). Any report referenced here should be listed in Section 10, Record of Communication. More than one may apply.) i. Basis for unconditional closure ii. Explanation iii. For More Information Title of report and section/page, figure or table number(s) A. Contaminant levels indicate that it is unnecessary to restrict any use of the site. B. The site does not require an Institutional Control (IC) to effect use restrictions. C. The site does not require ongoing monitoring, remediation or reporting. c. Conditional closure. (If conditional closure, select and briefly explain why conditional closure is appropriate. More than one may apply): i. Contamination exists above remediation within the area of exposure control (AEC). ii. Contamination exists above remediation outside the AEC. iii. Reference. Provide the title of the report where detailed information may be located, and the location of the pertinent information within that report (e.g. page(s) section(s), table or figure number(s)). Any report referenced here should be listed in Section 10, Record of Communication. A. Title B. Location C. RECORD OF SITE CLOSURE Page 2 of 6

3 7. CONDITIONS SUBSEQUENT TO CLOSURE (REQUIRED FOR CONDITIONAL CLOSURE) a. Third party property interest or other formal agreement. (If any third party property interest or other formal agreement is needed to ensure that the remedy remains protective, identify the third party property address, and the nature of the property interest or agreement needed.) b. Inspection or operation and maintenance (O&M). If any inspection or O&M is expected, provide the title, date and the 8-digit Virtual File Cabinet (VFC) document number of the O&M plan. The O&M plan should include: Inspection or maintenance required, description and frequency; Monitoring required, description and frequency; Recordkeeping requirements, and Equipment manuals or SOPs. All system O&M information is in Remediation Work Plan or Corrective Action Plan A. Title B. Date (mm, dd, yyy) C. VFC Document Number (xxxxxxxx) c. Financial assurance. (Details regarding financial assurance, if necessary to assure the continued effectiveness of the remedy.) i. Amount ii. Type of instrument iii. Frequency and type or reporting required iv. Period of effectiveness v.beneficiary 8. OVERVIEW OF CONCEPTUAL SITE MODEL (CSM) AND SITE RISK CHARACTERIZATION. Information from a previous Record of Remedy Selection does not need to be repeated here. (Complete this section only if: 1) You did not previously submit a Record of Remedy Selection, or 2) Your remedial actions included measures intended to reduce the level of contamination. If there is a Record of Remedy Selection for this remedial or corrective action, only new information needs to be entered here.) a. Soil direct contact (residential, industrial, recreational and excavation/construction worker). Enter information in the sections below. concentrations exist that are above the remediation, but the contamination does not contribute to contaminants were above remediation B.Contaminants C. Concentrations of contaminants D.Remediation RECORD OF SITE CLOSURE Page 3 of 6

4 b. Ground water ingestion and soil migration to groundwater. (Enter information in the sections below.) concentrations exist that are above the remediation, but the contamination does not contribute to contaminants were above remediation B. Contaminants C. Concentrations of contaminants D. Remediation c. Vapor intrusion. (Enter information in the sections below.) concentrations exist that are above the remediation, but the contamination does not contribute to contaminants were above remediation B. Contaminants C. Concentrations of contaminants D. Remediation d. Other human health or ecological scenario. (Specify scenario.) Enter information in the sections below. concentrations exist that are above the remediation, but the contamination does not contribute to contaminants were above remediation B. Contaminants C. Concentrations of contaminants D. Remediation RECORD OF SITE CLOSURE Page 4 of 6

5 9. DESCRIPTION OF PUBLIC PARTICIPATION (if applicable) Provide information about any public participation activities that were performed since the Record of Remedy Selection (if any) was approved. The level of public participation required is established by rule, policy, or law and is specific to the remediation program. Types of public participation may include: Letter to health department or official; Direct contact or notification of potentially affected parties; Fact Sheet; Public notice; Availability Session; Public meeting; and Other. a. Date (mm, dd, yyy) b. Type of public participation c. Location (for any meeting or availability session); or Name of publication (for any public notice or ad); or Address(s) of party(s) notified. Not Applicable. (No public participation was required.) 10. RECORD OF COMMUNICATION Provide a list of key decision documents (i.e. Corrective Action Plan (CAP) or Remediation Work Plan (RWP) revisions or amendments, request for No Further Action (NFA), as-built drawings, Remediation Completion Report, Certificate of Completion, any legal agreements, a Record of Remedy Selection [if any], and any other key documents that were generated since the Record of Remedy Selection [if any]). a. Document title b. Document (mm, dd, yyy) c. Preparer d. VFC document number (xxxxxxxx) 11. ATTACHMENTS a. Figure(s) that illustrates site features, surrounding area, land use, area of exposure control, and all sample locations that reflect current conditions. (See Section 5) b. Table(s) of sample results that reflect current conditions and remediation. (See Section 5) c. Environmental Restrictive Ordinance (ERO). Copy of each legally adopted ERO used as an exposure control measure. d. Environmental Restrictive Covenant (ERC). Copy of each recorded ERC(s) used as an exposure control measure. 12. SIGNATURE OF PREPARER OF THIS REPORT. Name Position Company Date (mm, dd, yyy) Enter professional credentials for sites addressed under 329 Indiana Administrative Code (IAC) , 329 IAC 9-5-6, or 329 IAC 9-5-7, or if required by a site specific agreement., Environmental Professional Credential Signature RECORD OF SITE CLOSURE Page 5 of 6

6 13. THIS SECTION TO BE COMPLETED BY THE INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT. Approval of Site Closure Closure status may be rendered ineffective if new information indicates potential unacceptable risk to human health, or if the terms of any ERC, ERO or other Conditions Subsequent to Closure are not being met. Name Title Date (mm, dd, yyy) Signature RECORD OF SITE CLOSURE Page 6 of 6