analytical results applicable VolC, ≤ as determined by 22a-133k-3(c) OR Compliance with VolC in Soil Vapor (ii) Sampling locations and frequency are representative of soil vapor, including seasonal variability, and analytical results applicable VolC ≤ Release Area (RA) ID 11. Other Provisions or Site-Wide #’s Application of on Up-Gradient DEEP “Policy Contamination” (8/28/97) Variance of groundwater remediation due to Technical 22a-133k-3(e)(2) Impracticability (Commissioner approval) Approval date(s): Copy(s) of Approval(s) must be attached to VR Date Certificate of Title for recordation of ELUR submitted to Commissioner: Copy of Certificate of Title page (with volume, page, and date recorded) must be attached to VR Rem#: Part VI: Receptors Groundwater Class: Depth to Water Table: Surface Water Class: Name of and Distance to nearest downgradient surface water body: Abutting land uses Industrial Commercial Residential Agriculture (check all that apply): school childcare facility healthcare facility Sensitive receptor land use recreational residential within 500 feet of site Sensitive Water Resource (e.g. shellfish beds, public fishing areas, significant (check all that apply): wetland complexes, public water supplies) other (specify): If groundwater impacted, indicate number of water supply wells within 500 feet of site boundaries: Water Supply Well Receptor Survey completed and submitted to the Commissioner: Yes No Has a groundwater plume that originated on-site migrated off-site? Yes No Number of water supply wells impacted from releases originating from on-site source: Water Main connection Date: Permanent potable water supply provided by: Filtration Monitoring frequency:
analytical results ≤ applicable VolC, as determined by 22a-133k-3(c) OR Compliance with VolC in Soil Vapor (ii) Sampling locations and frequency are representative of soil vapor, including seasonal variability, and analytical results ≤ applicable VolC 11. Other Provisions Release Area (RA) ID #’s or Site-Wide Application of DEEP “Policy on Up-Gradient Contamination” (8/28/97) Variance of groundwater remediation due to Technical Impracticability (Commissioner approval) Approval date(s): 22a-133k-3(e)(2) Copy(s) of Approval(s) must be attached to VR Date Certificate of Title for recordation of ELUR submitted to Commissioner: Copy of Certificate of Title page (with volume, page, and date recorded) must be attached to VR Rem#: Part VI: Receptors Groundwater Class: Depth to Water Table: Surface Water Class: Name of and Distance to nearest downgradient surface water body: Abutting land uses (check all that apply): Industrial Commercial Residential Agriculture Sensitive receptor land use within 500 feet of site (check all that apply): school childcare facility healthcare facility recreational residential Sensitive Water Resource (e.g. shellfish beds, public fishing areas, significant wetland complexes, public water supplies) other (specify): If groundwater impacted, indicate number of water supply wells within 500 feet of site boundaries: Water Supply Well Receptor Survey completed and submitted to the Commissioner: Yes No Has a groundwater plume that originated on-site migrated off-site? Yes No Number of water supply wells impacted from releases originating from on-site source: Permanent potable water supply provided by: Water Main connection Date: Filtration Monitoring frequency:
form_iii_verification_property_interim.docx