HomeMy WebLinkAbout2013-09-03 Planning Board Supplemental Materials (17) Massachusetts Department of Environmental Protection BWSC106
Bureau of Waste Site Cleanup
RELEASE ABATEMENT MEASURE (RAM) Release Tracking Number
TRANSMITTAL FORM
- 4565.... .................�.�.�
IL7: —I Pursuant to 310 CMR 40.0444-0446 (Subpart D)
A. SITE LOCATION:
1. Site Name/Location Aid: CNS!NPC,MTFSVMF!TUBlJPO!12.531
2. Street Address: 5: 9!DI DLFSJJH'SE
OPSUI !BOEPVIFS����������������������������������������������������� 1295611�1�1�����������������������������������������������������
ZIP Code.
3. City/Town: 4. ............................................................................................................................................................................................
5. UTM Coordinates: a. UTM N: 583:136 __ � b. UTM E: ,4„3„ 44„4...........
..........
II 6. Check here if a Tier Classification Submittal has been provided to DEP for this disposal site.
❑ a. Tier IA ❑ b. Tier 113 ❑ c. Tier IC ❑ d. Tier 11
7. If a Tier I Permit has been issued, provide Permit Number:
B.THIS FORM IS BEING USED TO: (check all that apply)
1. List Submittal Date of Initial RAM Plan (if previously submitted): .......................................................................................................................................�
(mm/dd/yyyy)
2. Submit an Initial Release Abatement Measure(RAM)Plan.
a. Check here if the RAM is being conducted as part of the construction of a permanent structure. If checked, you must
❑ specify what type of permanent structure is to be erected in or in the immediate vicinity of the area where the RAM is to
be conducted.
b. Specify type of permanent structure: (check all that apply) ❑ i. School ❑ ii. Residential ❑ iii. Commercial
❑ iv. Industrial ❑ v.Other Specify:
3. Submit a Modified RAM Plan of a previously submitted RAM Plan.
4. Submit a RAM Status Report.
� 5. Submit a Remedial Monitoring Report. (This report can only be submitted through eDEP, concurrent with a RAM Status
III Report.)
a.Type of Report: (check one) ❑ i. Initial Report ❑ ii. Interim Report ❑ iii. Final Report
b. Number of Remedial Systems and/or Monitoring Programs:
A separate BWSC106A, RAM Remedial Monitoring Report, must be filled out for each Remedial System
and/or Monitoring Program addressed by this transmittal form.
6. Submit a RAM Completion Statement.
7. Submit a Revised RAM Completion Statement.
8. Provide Additional RTNs:
a. Check here if this RAM Submittal covers additional Release Tracking Numbers (RTNs). RTNs that have been
previously linked to a Primary Tier Classified RTN do not need to be listed here. This section is intended to allow a
RAM to cover more than one unclassified RTN and not show permanent linkage to a Primary Tier Classified RTN.
b. Provide the additional Release Tracking Number(s) ❑ _ ❑ _
covered by this RAM Submittal.
(All sections of this transmittal form must be filled out unless otherwise noted above)
Revised: 2/16/2005 Page 1 of 6
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup BWSC106
RELEASE ABATEMENT MEASURE (RAM) Release Tracking Number
TRANSMITTAL FORM 4 � - 456 5,
mmm , ,A, b Pursuant to 310 CMR 40.0444-0446 (Subpart D)
C. RELEASE OR THREAT OF RELEASE CONDITIONS THAT WARRANT RAM:
1. Identify Media Impacted and Receptors Affected: (check all that apply)
a. Air DI b. Basement c. Critical Exposure Pathway L .....III d. Groundwater L.......... e. Residence
f. Paved Surface g. Private Well h. Public Water Supply i. School 7 j. Sediments
k. Soil I. Storm Drain m. Surface Water 0 n. Unknown 0 o. Wetland L......... p. Zone 2
q. Others Specify:
2. Identify all sources of the Release or Threat of Release, if known: (check all that apply)
a. Above-ground Storage Tank(AST) b. Boat/Vessel c. Drums d. Fuel Tank
e. Pipe/Hose/Line L..........� f. Tanker Truck L.......... g. Transformer L.5..... h. Under-ground Storage Tank(UST)
i. Vehicle III j. Others Specify:
3. Identify Oils and Hazardous Materials Released: (check all that apply)
L.5.....� a. Oils L.......... b. Chlorinated Solvents 5 c. Heavy Metals
L..........� d. Others Specify:
NBTPMF
D. DESCRIPTION OF RESPONSE ACTIONS: (check all that apply, for volumes list cumulative amounts)
1. Assessment and/or Monitoring Only L.......... 2. Temporary Covers or Caps
3. Deployment of Absorbent or Containment Materials 4. Temporary Water Supplies
5. Structure Venting System 6. Temporary Evacuation or Relocation of Residents
L.......
7. Product or NAPL Recovery III 8. Fencing and Sign Posting
9. Groundwater Treatment Systems 10. Soil Vapor Extraction
11. Bioremediation 12. Air Sparging
Revised: 2/16/2005 Page 2 of 6
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup BWSC106
RELEASE ABATEMENT MEASURE (RAM) Release Tracking Number
TRANSMITTAL FORM 4
- 4565
mmm , ,A, b Pursuant to 310 CMR 40.0444-0446 (Subpart D)
D. DESCRIPTION OF RESPONSE ACTIONS(cont.): (check all that apply, for volumes list cumulative amounts)
5 13. Excavation of Contaminated Soils
5❑ a. Re-use, Recycling or Treatment i. On Site Estimated volume in cubic yards
5❑ ii. Off Site Estimated volume in cubic yards 3611
iia. Receiving Facility: I BV\FSI JVMNBOEGJVM Town: I BV\FSI JAM State: NB
iib. Receiving Facility: OBTI VB!NBOEG.NM Town: OBTI VB State: OI
iii. Describe: CFUSPM=VN!DPOUBNJDBUFE!TPJAI
b. Store F-1 i. On Site Estimated volume in cubic yards
ii. Off Site Estimated volume in cubic yards
iia. Receiving Facility: Town: State:
iib. Receiving Facility: Town: State:
El c. Landfill
i. Cover Estimated volume in cubic yards
Receiving Facility: Town: State:
ii. Disposal Estimated volume in cubic yards
Receiving Facility: Town: State:
L.......... 14. Removal of Drums, Tanks or Containers:
a. Describe Quantity and Amount:
b. Receiving Facility: Town: State:
c. Receiving Facility: Town: State:
L.......... 15. Removal of Other Contaminated Media:
a. Specify Type and Volume:
b. Receiving Facility: Town: State:
c. Receiving Facility: Town: State:
16. Other Response Actions:
Describe:
17. Use of Innovative Technologies:
Describe:
Revised: 2/16/2005 Page 3 of 6
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup BWSC106
RELEASE ABATEMENT MEASURE (RAM) Release Tracking Number
TRANSMITTAL FORM 4 _ 4565
7IGNATUR Pursuan t to 310 CMR 40.0444-0446 (Subpart D)
E AND STAMP:
I attest under the pains and penalties of perjury that I have personally examined and am familiar with this transmittal form,
including any and all documents accompanying this submittal. In my professional opinion and judgment based upon application
of(i)the standard of care in 309 CMR 4.02(1), (ii)the applicable provisions of 309 CMR 4.02(2)and (3), and 309 CMR 4.03(2), and
(iii)the provisions of 309 CMR 4.03(3),to the best of my knowledge, information and belief,
> if Section 8 of this form indicates that a Release Abatement Measure Planis being submitted,the response action(s)that is
(are)the subject of this submittal (i)has(have)been developed in accordance with the applicable provisions of M.G.L. c.21 E and
310 CMR 40.0000, (ii)is(are)appropriate and reasonable to accomplish the purposes of such response action(s)as set forth in
the applicable provisions of M.G.L. c.21 E and 310 CMR 40.0000 and (iii)comply(ies)with the identified provisions of all orders,
permits, and approvals identified in this submittal;
> if Section 8 of this form indicates that a Release Abatement Measure Status Report and/or Remedial Monitoring Report is
being submitted, the response action(s)that is(are)the subject of this submittal (i)is(are)being implemented in accordance
with the applicable provisions of M.G.L. c. 21 E and 310 CMR 40.0000, (ii)is(are)appropriate and reasonable to accomplish the
purposes of such response action(s)as set forth in the applicable provisions of M.G.L. c.21 E and 310 CMR 40.0000 and (iii)
comply(ies)with the identified provisions of all orders, permits, and approvals identified in this submittal;
> if Section 8 of this form indicates that a Release Abatement Measure Completion Statement is being submitted, the response
action(s)that is(are)the subject of this submittal (i)has(have)been developed and implemented in accordance with the
applicable provisions of M.G.L. c.21 E and 310 CMR 40.0000, (ii)is(are)appropriate and reasonable to accomplish the purposes
of such response action(s)as set forth in the applicable provisions of M.G.L. c. 21 E and 310 CMR 40.0000 and (iii)comply(ies)
with the identified provisions of all orders, permits, and approvals identified in this submittal:
I am aware that significant penalties may result, including, but not limited to, possible fines and imprisonment, if I submit
information which I know to be false, inaccurate or materially incomplete.
1. LSP#: .2.9.5.8..........................1
XBNB� 3. Last Name: T,NNPOT
2. First Name.
4. Telephone: -89574777:
p 5. Ext.: 6 FAX.
X njbn 'B'T,nn pot
7. Signature:
e of
3C65C6124
8. Date: 9. LSP Stamp: `
(mm/dd/yyyy)
Electronics
Sea lI
Sit K0
Revised: 2/16/2005 Page 4 of 6
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup BWSC106
RELEASE ABATEMENT MEASURE (RAM) Release Tracking Number
TRANSMITTAL FORM 4 4565,,,
L Pursuant to 310 CMR 40.0444-0446 (Subpart D)
F. PERSON UNDERTAKING RAM:
1. Check all that apply: 5 a. change in contact name b. change of address c. change in the person
............................................................
.........................................u.....n.....d.....e......r...t...a......k.....i..n.....g........r...e.....s......p.....o......n.....s.....e........a.....c.....t...i..o......n.....s QBSL.TUSFFU.SFEFV\FPQN FOUMD 2. Name of Organization: ....
......
3. Contact First Name: IVPVJf.Q 4. Last Name: ...N.. V . . .KS.................................................................................................................................
NBOBHFS
342!TVUUP O!TU
6.Title.
5. Street. ...................................................................................................................................................................................................................
7. City/Town: OPSUI .BOEPV�FS 8. State: NB 9. ZIP Code:
.. .9..5.6.......................................................
:....89.7.9873.1...1......................................................................... 11. Ext.: 12. FAX:
10. Tele hone:
p ............................................................�
G. RELATIONSHIP TO RELEASE OR THREAT OF RELEASE OF PERSON UNDERTAKING RAM:
5 III 1. RP or PRP � : �
.... a. Owner � b. Operator � c. Generator � d. Transporter
..........
e. Other RP or PRP Specify:
...................................................................................................................................................................................................................................................................................................................................
II 2. Fiduciary, Secured Lender or Municipality with Exempt Status(as defined by M.G.L. c.21 E,s.2)
L......... 3. Agency or Public Utility on a Right of Way(as defined by M.G.L. c.21 E,s.50))
4. Any Other Person Undertaking RAM Specify Relationship:
H.REQUIRED ATTACHMENT AND SUBMITTALS:
1. Check here if any Remediation Waste,generated as a result of this RAM,will be stored,treated, managed, recycled or
reused at the site following submission of the RAM Completion Statement. You must submit a Phase IV Remedy
Implementation Plan along with the appropriate transmittal form(BWSC108).
2. Check here if the Response Action(s)on which this opinion is based, if any, are (were)subject to any order(s), permit(s)
and/or approval(s)issued by DEP or EPA. If the box is checked,you MUST attach a statement identifying the applicable
provisions thereof.
3. Check here to certify that the Chief Municipal Officer and the Local Board of Health have been notified of the
implementation of a Release Abatement Measure.
4. Check here if any non-updatable information provided on this form is incorrect,e.g. Release Address/Location Aid. Send
corrections to the DEP Regional Office.
5. If a RAM Compliance Fee is required for this RAM, check here to certify that a RAM Compliance Fee was submitted to
DEP, P. O. Box 4062, Boston, MA 02211.
5 6. Check here to certify that the LSP Opinion containing the material facts,d ata, and other information is attached.
Revised: 2/16/2005 Page 5 of 6
Massachusetts Department of Environmental Protection
L71Bureau of Waste Site Cleanup BWSC106
RELEASE ABATEMENT MEASURE (RAM) Release Tracking Number
TRANSMITTAL FORM - 4565
Pursuant to 310 CMR 40.0444-0446 (Subpart D)
I. CERTIFICATION OF PERSON UNDERTAKING RAM:
1. I,IIIVpv�t .Q.N�o�dvdd� , attest under the pains and penalties of perjury(i)that I have personally
M...............................................................................................................................................................................................................
examined and am familiar with the information contained in this submittal, including any and all documents accompanying this
transmittal form, (ii)that, based on my inquiry of those individuals immediately responsible for obtaining the information, the
material information contained in this submittal is,to the best of my knowledge and belief,true, accurate and complete, and (iii)
that I am fully authorized to make this attestation on behalf of the entity legally responsible for this submittal. I/the person or
entity on whose behalf this submittal is made am/is aware that there are significant penalties, including, but not limited to,
possible fines and imprisonment,for willfully submitting false, inaccurate, or incomplete information.
2. By: Wvjt .Q.Njojdvddj N BOBHFS
3. Title.
Signature
..........................................................................................................................................................L................................................................................................................
4. For: QBSL.L TUSFFU.LSFEFV\FIVPQNFOUMD 5. Date: .3.(B5.(B1..2.4.............................................................................................................
(Name of person or entity recorded in Section F) (mm/dd/yyyy)
6. Check here if the address of the person providing certification is different from address recorded in Section F.
7. Street:
8. City/Town: 9. State: 10. ZIP Code:
11. Telephone: 12. Ext.: 13. FAX:
YOU ARE SUBJECT TO AN ANNUAL COMPLIANCE ASSURANCE FEE OF UP TO$10,000 PER
BILLABLE YEAR FOR THIS DISPOSAL SITE. YOU MUST LEGIBLY COMPLETE ALL RELEVANT
SECTIONS OF THIS FORM OR DEP MAY RETURN THE DOCUMENT AS INCOMPLETE. IF YOU
SUBMIT AN INCOMPLETE FORM,YOU MAY BE PENALIZED FOR MISSING A REQUIRED DEADLINE.
Date Stamp(DEP USE ONLY:)
Sf df jd e!cz!EFQ!po
3CB5CB124!7;62;38!QN
Revised: 2/16/2005 Page 6 of 6