New Jersey Department of Environmental Protection Unregulated Heating Oil Tank Program Questionnaire
I. General Information 1. Site Name ________________________________________________ Street Address _____________________________________Zip Code ______________ Municipality ________________________ County __________________ List all tax block and lot numbers that are the subject of this submittal (hereinafter, the Site) Block(s) ____________________________ Lot(s) _________________________________ Latitude __________________ Longitude __________________ Acreage ____________ Geographic boundaries ________________________________________________________ __________________________________________________________________________ EPA ID # (if applicable) _________________________________________ DEP incident # (if applicable) _________________________________________ 2. Full Name of Applicant _____________________________________________ Address __________________________________________________ City ________________________ State _______ Zip Code ___________ Telephone # ___________________ Email Address __________________________________ 3. Indicate phase(s) of the remediation and the document(s) being submitted to the Department for review: Remedial Phase [ ] Site Investigation Documents Fixed Oversight Costs $400.00
[ ] Site Investigation Report $400.00
[ ] Remedial Investigation/Remedial Action [ ] Remedial Action Report
4. Current Use: Agricultural ______ Industrial _____ Undeveloped _____ Residential ______ Commercial ______ Other _______________________________ 5. Current Site/Business Owner(s) (if applicable) Name(s) ________________________________________________________________ Firm __________________________________ Telephone # _______________________ Street Address ________________________________________________ Municipality ________________________State _______________ Zip Code ___________
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7. Has the property been or is the property currently the subject of any remediation with DEP oversight? If Yes, provide the following: Case Number _________________________________________________ Communication Center #: ___________________________________ Case Lead (Program) ___________________________________________ Case Manager _________________________________________________ Case Status ___________________________________________________ 8. Name of the pre-qualified environmental professional: ___________________________________________________________________
[ ] Yes
[ ] No
Firm ____________________________________________________________________ Street Address __________________________________________________ Municipality ____________________________________________________ State ___________________________ Zip Code ______________ Individual UST Certification #: ____________________________________ Firm UST Certification #: ____________________________________ 9. Has a Grant Application for the Petroleum Underground Storage Tank Remediation, Upgrade and Closure Fund ("UST Fund") been filed with the Department in connection with the Site? If yes, indicate the date of application and status of application. __________________________________________________________________ If no, will any applications be filed in the future? [ ] Yes [ ] No
II. Site Specific Information
1. List the size of the non-regulated tanks subject to the submittal. Attach a map providing UST location(s), sample location(s) and depth(s), and sample results. Attach additional sheets, if needed. ___________________________________________________________________________ ___________________________________________________________________________ 2. Was a discharge of a hazardous substance, contaminant or pollutant identified? If so, was the discharge to: (check all that apply) Soil [ ] Ground Water [ ] Surface Water [ ] Ecologically Sensitive Area [ ] [ ] Yes [ ] No
Other [ ] (specify) _______________________________________________________________
3. How was the discharge identified? (check all that apply)
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Sample Analysis [ ] Olfactory [ ] Visual [ ] Record/Loss of Product [ ] Chemical analysis [ ] Other [ ] (specify)
________________________________________________________________________________ 4. Were any of the following conditions present ? (check all that apply.) Soil Staining [ ] Distressed or Dead Vegetation [ ] Product Entering Storm Sewer [ ] Product Entering Basement [ ] Off-site Migration [ ] Product Observed on Surface Water [ ]
Other [ ] (specify) _______________________________________________________________
III.
Soils 1. Were soil samples collected in accordance with the provisions of N.J.A.C. 7:26E and the Department’s most recent Field Sampling Procedures Manual?
[ ] Yes
[ ] No [ ] No
2. Were soil samples biased toward the most contaminated areas using field instruments and/or visual and olfactory observations? [ ] Yes How was this accomplished? _________________________________________________________ 3. Was the vertical and horizontal extent of soil contamination delineated prior to remediation? ________________________________________________________________________________
4. Fully describe the method of soil remediation? _______________________________________________ _________________________________________________________________________________ 5. If excavation was performed, what was the depth of the bottom of the excavation? ____________ feet. 6. Was contaminated soil removed from the site? How much soil was removed? __________________ tons/cubic yards (circle one) To what facility was the soil taken? ______________________________________________________ Date taken: ________________________________ If no soil was removed, was it reused on site? [ ]Yes [ ]No [ ]Yes [ ]No
7. If soil was reused onsite, was sampling conducted pursuant to the N.J.A.C. 7:26E-6.4(d) and the Guidance Document for the Remediation of Contaminated Soils? [ ]Yes
[ ]No [ ]No [ ]No
8. Did the Department approve the reuse plan prior to implementation?
[ ]Yes
9. Were the analytical results for all soil post excavation/remediation samples below the Department’s most stringent soil cleanup criteria? [ ]Yes IV. Ground Water 1. What is the approximate depth to saturated zone (seasonally high water table)? ______________ feet.
How was this determined? ____________________________________________________________ 2. What is the approximate depth to bedrock? ______________ feet.
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How was this determined? __________________________________________________________ 3. What is the percentage of silt/clay in the soil between the contaminant and the saturated zone or bedrock? ____________________. How was this determined? _____________________________________ _________________________________________________________________________________ 4. Was ground water present in the excavation? [ ] No If yes, was there a sheen observed on ground water? [ ] Yes [ ] No [ ] No [ ] Yes
5. Are there any public supply wells within 2,000 feet of confirmed soil contamination? [ ] Yes
How was this determined? ____________________________________________________________ 6. Was a ground water investigation conducted in accordance with N.J.A.C.7:26E 3.7 or 4.4? 7. Were all ground water samples collected in accordance with N.J.A.C. 7:26E and the Department’s most recent Field Sampling Procedures Manual? [ ] Yes [ ] Yes [ ] No [ ] N/A
[ ] No [ ] N/A
Include all Monitoring well permit #s ______________________________________________ 8. Was any contamination detected in the ground water above the applicable Ground Water Quality Standards, N.J.A.C. 7:9-6? [ ] Yes [ ] No
9. Was the vertical and horizontal extent of ground water contamination delineated prior to remediation? [ ] Yes 10. Does ground water contamination extend beyond the property boundary? 11. Is a private potable well located within 100 feet of the area of concern? (either on or off the property) [ ] Yes
[ ] No [ ] No
[ ] N/A [ ] N/A [ ] No
[ ] Yes
If yes, what is the distance from the area of concern to the private potable well ______________ ft 12. Was a well search conducted pursuant to N.J.A.C. 7:26E-3.7(e)3? [ ] Yes [ ] No [ ] N/A
13. Fully describe the method of ground water remediation? __________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 14. Was contaminated ground water removed from the site? What volume was removed? __________________ gallons To what facility was it taken? ______________________________________________________________ Date taken: ________________________________ 15. Was ground water remediation conducted under the authority of a NJPDES Permit-by-Rule? 16. Was ground water remediation conducted under On-Scene Coordinator Discharge Authorization? 17. Are there two rounds of confirmatory sampling that indicate ground water is below the applicable Ground Water Quality Standards, N.J.A.C. 7:9-6?
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[ ] Yes
[ ] No
[ ] Yes [ ] Yes [ ] Yes [ ] No
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[ ] No [ ] No [ ] N/A
16. Was a vapor intrusion investigation conducted accordance with N.J.A.C. 7:26E-4.4(h)3.viii?
[ ] Yes
[ ] No
[ ] N/A
V.
Remedial Action Requirements 1. Was the site restored in accordance with N. J.A.C. 7:26E-6.4(b)? 2. Was a Baseline Ecological Evaluation conducted pursuant to N.J.A.C 7:26E? [Not applicable to residential heating oil tanks (1-4 families)] If yes, is there a contaminant of concern present? Are there environmentally sensitive natural resources within or surrounding the property? [ ] No Are there potential contaminant migration pathways present? Were potential ecological impacts identified? 3. Was the remedial investigation/action report prepared in accordance with N.J.A.C. 7:26E? 4. Remediation completion date: ________________ 5. What was the total cost of the remediation? $ __________________ 6. Subcontractors employed during the investigation/remediation (list all): [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No [ ] No
[ ] Yes
[ ] No
Name/Address: __________________________________________________________________________
Name/Address: __________________________________________________________________________
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Site Investigation - Remedial Investigation/Action Report Checklist: • • • • • • • • • • • • • • • • • • • • • Contaminated Soil Disposal Receipt (fully executed manifest) Tank Disposal Certificate Tank Contents Disposal Receipt (fully executed manifest) Fill was “certified clean” in accordance with N.J.A.C.7:26E-6.4 Contaminated Ground Water Disposal Receipt (fully executed manifest) All local permits submitted USGS Topographic map of the area Scaled site map with AOCs and north arrow Sample Results Summary Tables (N.J.A.C.7:26E-4.8) Laboratory was certified to perform the required tests Chain of Custody forms submitted Signed laboratory deliverables checklist and Non-Conformance Summaries submitted Problems identified in the laboratory deliverables checklist and Non-Conformance summaries Holding times were met for all analyses MDLs below most stringent soil cleanup criteria Laboratory sample summary submitted QA/QC package (reduced deliverables) submitted VOC soil samples methanol preserved (sample weights included) Electronic data package (home heating oil tanks exempt) Well search submitted Baseline Environmental Evaluation (home heating oil tanks exempt) [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA
[ ] Yes
[ ] No
[ ] NA
[ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes
[ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No
[ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA [ ] NA
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