Release Area (RA) 10. Compliance with VolC 22a-133k-3(g)(2)(D) or Site-Wide ID #’s Compliance with VolC in Groundwater (i) Sampling locations are representative of plume, and 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 ≤ Lot: Block: Map: Town: Release Area (RA) 11. Other Provision or Site-Wide ID #’s Application of on Up-Gradient DEEP “Policy Contamination” (8/28/97) 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): Did any on-site release have the potential to impact an Ecological Receptor Yes No If yes, were the potential ecological exposure pathways, where contaminants could Yes No affect aquatic and terrestrial life, evaluated If yes, what level of evaluation was completed? Scoping Screening Risk Assessment If yes, was the ecological receptor impacted by an on-site release? Yes No Was the impact mitigated? Yes No If groundwater impacted, indicate number of water supply wells within 500 feet of site boundaries: Has a groundwater plume that originated on-site migrated off-site? Yes No
10. Compliance with VolC 22a-133k-3(g)(2)(D) Release Area (RA) ID #’s or Site-Wide Compliance with VolC in Groundwater (i) Sampling locations are representative of plume, and 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 Lot: Block: Map: Town: 11. Other Provision Release Area (RA) ID #’s or Site-Wide Application of DEEP “Policy on Up-Gradient Contamination” (8/28/97) 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): Did any on-site release have the potential to impact an Ecological Receptor Yes No If yes, were the potential ecological exposure pathways, where contaminants could affect aquatic and terrestrial life, evaluated Yes No If yes, what level of evaluation was completed? Scoping Screening Risk Assessment If yes, was the ecological receptor impacted by an on-site release? Yes No Was the impact mitigated? Yes No If groundwater impacted, indicate number of water supply wells within 500 feet of site boundaries: Has a groundwater plume that originated on-site migrated off-site? Yes No
form_i_verification_property.docx