§620.APPENDIX D. Confirmation of an Adequate Corrective Action Pursuant to 35 Ill. Adm. Code 620.250(a)(2)

Pursuant to 35 Ill. Adm. Code 620.250(a) if an owner or operator provides a written confirmation to the Agency that an adequate corrective action, equivalent to a corrective action process approved by the Agency, is being undertaken in a timely and appropriate manner, then a groundwater management zone may be established as a three-dimensional region containing groundwater being managed to mitigate impairment caused by the release of contaminants from a site.  This document provides the form in which the written confirmation is to be submitted to the Agency.

 

Note 1.	Parts I and II are to be submitted to IEPA at the time that the facility claims the alternative groundwater standards.  Part III is to be submitted at the completion of the site investigation.  At the completion of the corrective process, a final report is to be filed which includes the confirmation statement included in Part IV.
Note 2.	The issuance of a permit by IEPA's Division of Air Pollution Control or Water Pollution Control for a treatment system does not imply that the Agency has approved the corrective action process.
Note 3.	If the facility is conducting a cleanup of a unit which is subject to the requirements of the Resource Conservation and Recovery Act (RCRA) or the 35 Ill. Adm. Code 731 regulations for Underground Storage Tanks, this confirmation process is not applicable and cannot be used.
Note 4.	If the answers to any of these questions require explanation or clarification, provide such in an attachment to this document.

 

 

Part I.	Facility Information
	Facility Name
	Facility Address
	County
Standard Industrial Code (SIC)

 

1.         Provide a general description of the type of industry, products manufactured, raw materials used, location and size of the facility.

 

2.         What specific units (operating or closed) are present at the facility which are or were used to manage waste, hazardous waste, hazardous substances or petroleum?

 

			YES		NO
Landfill
Surface Impoundment
Land Treatment
Spray Irrigation
Waste Pile
Incinerator
Storage Tank (above ground)
Storage Tank (underground)
Container Storage Area
Injection Well
Water Treatment Units
Septic Tanks
French Drains
Transfer Station
Other Units (please describe)

 

3.         Provide an extract from a USGS topographic or county map showing the location of the site and a more detailed scaled map of the facility with each waste management unit identified in Question 2 or known/suspected source clearly identified.  Map scale must be specified and the location of the facility must be provided with respect to Township, Range and Section.

 

4.         Has the facility ever conducted operations which involved the generation, manufacture, processing, transportation, treatment, storage or handling of "hazardous substances" as defined by the Illinois Environmental Protection Act?  Yes ___No ___ If the answer to this question is "yes" generally describe these operations.

 

5.         Has the facility generated, stored or treated hazardous waste as defined by the Resource Conservation and Recovery Act?  Yes ___ No ___If the answer to this question is "yes" generally describe these operations.

 

6.         Has the facility conducted operations which involved the processing, storage or handling of petroleum?  Yes ___No ____If the answer to this question is "yes" generally describe these operations.

 

7.         Has the facility ever held any of the following permits?

 

a.         Permits for any waste storage, waste treatment or waste disposal operation.  Yes ___ No ___ If the answer to this question is "yes", identify the IEPA permit numbers.

 

b.         Interim Status under the Resources Conservation and Recovery Act (filing of a RCRA Part A application).  Yes ___ No ___ If the answer to this question is "yes", attach a copy of the last approved Part A application.

 

c.         RCRA Part B Permits.  Yes ___ No ___ If the answer to this question is "yes", identify the permit log number.

 

8.         Has the facility ever conducted the closure of a RCRA hazardous waste management unit?  Yes ___ No ___

 

9.         Have any of the following State or federal government actions taken place for a release at the facility?

 

a.         Written notification regarding known, suspected or alleged contamination on or emanating from the property (e.g., a Notice pursuant to Section 4(q) of the Environment Protection Act)? Yes ___ No ___ If the to this question is "yes", identify the caption and date of issuance.

 

b.         Consent Decree or Order under RCRA, CERCLA, EPAct Section 22.2 (State Superfund), or EPAct Section 21(f) (State RCRA).  Yes ___ No ___

 

c.         If either of Items a or b were answered by checking "yes", is the notice, order or decree still in effect?  Yes ___ No ___

 

10.       What groundwater classification will the facility be subject to at the completion of the remediation?

 

Class I ____   Class II ___   Class III ____   Class IV ____

If more than one Class applies, please explain.

 

11.       Describe the circumstances which the release to groundwater was identified.

 

Based on my inquiry of those persons directly responsible for gathering the information, I certify that the information submitted is, to the best of my knowledge and belief, true and accurate.

 

Facility Name		Signature of Owner/Operator
Location of Facility		Name of Owner/Operator
EPA Identification Number		Date

 

 

PART II:  Release Information

 

1.        Identify the chemical constituents release to the groundwater.  Attach additional documents as necessary.

 

Chemical Description		Chemical Abstract No.

 

2.       Describe how the site will be investigated to determine the source or sources of the release.

 

3.       Describe how groundwater will be monitored to determine the rate and extent of the release.

 

4.       Has the release been contained on-site at the facility?

 

5.       Describe the groundwater monitoring network and groundwater and soil sampling protocols in place at the facility.

 

6.       Provide the schedule for investigation and monitoring.

 

7.       Describe the laboratory quality assurance program utilized for the investigation.

 

8.       Provide a summary of the results of available soil testing and groundwater monitoring associated with the release at the facility.  The summary or results should provide the following information:  dates of sampling; types of samples taken (soil or water); locations and depths of samples; sampling and analytical methods; analytical laboratories used; chemical constituents for which analyses were performed; analytical detection limits; and concentrations of chemical constituents in ppm (levels below detection should be identified as "ND").

 

Based on my inquiry of those persons directly responsible for gathering the information, I certify that the information submitted is, to the best of knowledge and belief, true and accurate and confirm that the actions identified herein will be undertaken in accordance with the schedule set forth herein.

 

Facility Name		Signature of Owner/Operator
Location of Facility		Name of Owner/Operator
EPA Identification Number		Date

 

 

Part III:  Remedy Selection Information

 

1.         Describe the selected remedy.

 

2.         Describe other remedies which were considered and why they were rejected.

 

3.         Will waste, contaminated soil or contaminated groundwater be removed from the site in the course of this remediation?  Yes ___ No ___ If the answer to this question is "yes", where will the contaminated material be taken?

 

4.         Describe how the selected remedy will accomplish the maximum practical restoration of beneficial use of groundwater.

 

5.         Describe how the selected remedy will minimize any threat to public health or the environment.

 

6.         Describe how the selected remedy will result in compliance with the applicable groundwater standards.

 

7.         Provide a schedule for design, construction and operation of the remedy, including dates for the start and completion.

 

8.         Describe how the remedy will be operated and maintained.

 

9.         Have any of the following permits been issued for the remediation?

 

a.         Construction or Operating permit from the Division of Water Pollution Control.  Yes __ No ___

 

b.         Land treatment permit from the Division of Water Pollution Control. Yes ___ No ___ If the answer to this question is "yes", identify the permit number.

 

c.         Construction or Operating permit from the Division of Air Pollution Control.  Yes ___ No ___ If the answer to this question is "yes", identify the permit number.

 

10.      How will groundwater at the facility be monitored following completion of the remedy to ensure that the groundwater standards have been attained?

 

Based on my inquiry of those persons directly responsible for gathering the information, I certify that the information submitted is, to the best of my knowledge and belief, true and accurate and confirm that the actions identified herein will be undertaken in accordance with the schedule set forth herein.

Facility Name		Signature of Owner/Operator
Location of Facility		Name of Owner/Operator
EPA Identification Number		Date

 

 

PART IV:  Completion Certification

 

This certification must accompany documentation which includes soil and groundwater monitoring data demonstrating successful completion of the corrective process described in Parts I-III.

 

Facility Name
Facility Address
County
Standard Industrial Code (SIC)
Date

 

Based on my inquiry of those persons directly responsible for gathering the information, I certify that an adequate corrective action, equivalent to a corrective action process approved by the Agency, has been undertaken and that the following restoration concentrations are being met:

 

Chemical Name		Chemical Abstract No.		Concentration (mg/L)

 

Facility Name		Signature of Owner/Operator
Location of Facility		Name of Owner/Operator
EPA Identification Number		Date

 

(Source:  Amended at 36 Ill. Reg. 15206, effective October 5, 2012)