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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
 
I hereby certify that the responses provided above are, to the best of my knowledge and belief, true, accurate and complete.  I am aware that there 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 in which signature is witnessed)    
 
_______________________ County    
     
 

I, ______________________________________________, a Notary Public of said County and State, do hereby certify that _______________________________________________ did personally appear and sign before me this the __________ day of __________, __________.
 
 
___________________________________________________    
Notary Public (signature)    
 
     
    (OFFICIAL SEAL)
 
My commission expires:  _____________________________    
     





 

Environmental Consultant Certification Statement
 
I hereby certify that the responses provided above are, to the best of my knowledge and belief, true, 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 in which signature is witnessed)    
 
_______________________ County    
     
 

I, ______________________________________________, a Notary Public of said County and State, do hereby certify that ________________________________________________ did personally appear and sign before me this the __________ day of __________, __________.
 
 
___________________________________________________    
Notary Public (signature)    
 
     
    (OFFICIAL SEAL)
 
My commission expires:  _________________________