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Site Cleanup Questionnaire

Remediating parties should prepare this form with the assistance of an environmental consultant.  All cooperative parties are eligible for Branch-approved remedial actions.  Answer all questions, based on current information, and provide written descriptions where needed.
     

NCDENR Site Name, City and County ________________________________________________________
     
   

Circle One

 
1.   Is the site located on or immediately adjacent to residential property, schools, day-care centers or other sensitive populations?

If yes, please explain on a separate page.
 		   Y N
2.   What is the distance (from site property line) to the nearest residence, school or day-care center?  Please attach a map showing the site and nearest residence, school or daycare center.
 		   __________
3.   Is the site completely surrounded by a locked fence?
If no, please explain security measures at the site on a separate page.
 		   Y N
4.   Are site surface soils known to be contaminated?

If yes, or unknown, describe briefly on a separate page.
 		   Y N
5.   Is site groundwater known to be contaminated?

If yes, or unknown, describe briefly on a separate page.
 		   Y N
6.   Is site sediment or surface water known to be contaminated?

If yes, or unknown, describe briefly on a separate page.
 

   Y N
7.   Has groundwater contamination affected any drinking water wells?

If yes, or unknown, please explain on a separate page.
 

   Y N
8.   What is the distance to the nearest downgradient drinking water well?
 		   __________
9.   What is the distance to the nearest downstream surface water intake?
 		   __________
10.   Are hazardous vapors, air emissions or contaminated dust migrating into occupied residential, commercial or industrial areas?

If yes, or unknown, please explain on a separate page.
 

   Y N
11.   Have hazardous substances known to have migrated off property at concentrations in excess of Branch unrestricted-use remediation goals?

If yes, or unknown, please explain on a separate page.
 

   Y N
12.   Has the local community expressed concerns about contamination at the site?

If yes, or unknown, please explain on a separate page.
 

   Y N
13.   Based on current information, are there any sensitive environments located on the property (sensitive environments are identified in the Remedial Investigation Work Plans section of the IHSB "Guidelines for Assessment and Cleanup"at www.wastenotnc.org/sfhome/stateleadguidance.pdf)?

If yes, or unknown, please explain on a separate page.
 

   Y N
14.   Based on current information, has contamination from the site migrated into any sensitive environments?

If yes, or unknown, please explain on a separate page.
 

   Y N
15.   Do site contaminants include radioactive or mixed radioactive and chemical wastes?

If yes, or unknown, please explain on a separate page.
 

   Y N





 

Remediating Party Certification Statement
 
After first being duly sworn or affirmed, I, ____________________________, hereby state that: I am over the age of eighteen, I am competent to make this certification based upon my own personal knowledge and belief, and, to the best of my knowledge and belief, after thorough investigation, the information contained herein is accurate and complete.  I am aware that htere are significant penalties for willfully submitting false, inaccurate or incomplete information.
 
___________________________________________________   ________________________________________
(Signature of Remediating Party Representative)   (Date)
 
___________________________________________________    
(Printed Name and Title of Remediating Party Representative)    
 
___________________________________________________    
(Printed Name of Company)    
 
     
     
 
STATE OF _________________________________________    
     
COUNTY OF _______________________________________    
     
 
I, ______________________________________________, a Notary Public of said County and State, do hereby certify that _______________________________________________ personally appeared before me this day, produced proper identification in the form of _______________________________, was duly sworn and/or affirmed, and declared that he or she is the owner of the property referenced above or is a duly authorized agent of said owner and that, to the best of his or her knowledge and belief, after thorough investigation, the information contained in the above certification is accurate and complete, and he or she then signed this Certification in my presence.
 
WITNESS my hand and official seal the __________ day of _______________, 200__.
     
___________________________________________________    
Notary Public (signature)    
 
     
    (OFFICIAL SEAL)
 
My commission expires:  _____________________________    
     





 

Environmental Consultant Certification Statement
 
After first being duly sworn or affirmed, I, ____________________________________, hereby state that: I am over the age of eighteen, I am competent to make this certification based upon my own personal knowledge and belief, and, to the best of my knowledge and belief, after thorough investigation, the information contained herein is accurate and complete.  I am aware that there are significant penalties for willfully submitting false, inaccurate or incomplete information.
 
___________________________________________________   ________________________________________
(Signature)   (Date)
 
___________________________________________________    
(Printed Name)    
 
___________________________________________________    
(Printed Name of Environmental Consultant)    
 
     
     
STATE OF _________________________________________    
     
COUNTY OF _______________________________________    
     
I, ______________________________________________, a Notary Public of said County and State, do hereby certify that _______________________________________________ personally appeared before me this day, produced proper identification in the form of _______________________________, was duly sworn and/or affirmed, and declared that he or she is an environmental consultant for the property referenced above and that, to the best of his or her knowledge and belief, after thorough investigation, the information contained in the above certification is accurate and complete, and he or she then signed this Certification in my presence.
 
 
WITNESS my hand and official seal the __________ day of _______________, 200__.
 
 
___________________________________________________    
Notary Public (signature)    
 
     
    (OFFICIAL SEAL)
 
My commission expires:  _________________________