Free 51920.pdf - Indiana


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SITE CATEGORIZATION FOR PRIORITIZATION OF CLAIMS
State Form 51920 (R / 8-08)

328 IAC 1-3-3(a)(1) Indiana Department of Environmental Management Excess Liability Trust Fund INSTRUCTIONS:

Indiana Department of Environmental Management Office of Land Quality Excess Liability Trust Fund Telephone: (317) 234-0990 Fax number: (317) 234-0428

1. Please submit two copies of the completed form and one copy of any supporting documentation. 2. Document references are required in order for the form to be processed. List appropriate supporting documentation references, in the section below, for each line item criteria checked on the form. 3. Check all line item criteria that apply to the release. 4. After completing the form and determining the prioritization category, enter the appropriate category number into the SITE CATEGORY FOR CLAIMS PRIORITIZATION box located at the bottom of the form. 5. To adjust a sites prioritization category, submit a letter requesting that the site be re-categorized, along with the appropriate justification(s). Include an updated Site Categorization for Prioritization of Claims Form, along with any supporting documentation, to the Department for review.

NOTE:

Forms will not be processed with incomplete information (all sections of this survey must be completed) or if required supporting documentation is not provided as described in the instructions below. Claims cannot be processed without site categorization. The Department may request additional supporting documentation if it is deemed necessary to validate selected categorization criteria.

RETURN COMPLETED FORM TO:

Indiana Department of Environmental Management Office of Land Quality/ELTF Section 100 North Senate Avenue Indianapolis, IN 46204-2251

Facility ID Number: LUST Incident Number:

FOR DEPARTMENT USE ONLY Date Received:
Request to Re-Categorize Site IDEM Site Re-Categorization

Check the appropriate box: OWNER CERTIFICATION:

Initial Site Categorization

OATH: I certify that under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete.
NAME AND TITLE OF OWNER OR AUTHORIZED REPRESENTATIVE

SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE

DATE

(MM / DD / YYYY)

/

/

SUPPORTING DOCUMENT REFERENCES

EXAMPLE CITATIONS: Line 1.A Line 1.B Line 1.C Line 2.A Line 2.B Line 3.A Line 3.B Line 3.C Line 3.D Line 4.A Line 4.B

(1) Initial Site Characterization Report, dated October 27, 2003, p. 5; or (2) Further Site Investigation Report, dated December 10, 2003, Appendix B

CATEGORY 1 CRITERIA
If any of the following criteria apply, the site is prioritized in Category 1

Not Applicable

1.A

Petroleum or petroleum constituents are detected in a structure or a utility conduit, such as a storm sewer, sanitary sewer, or utility conduit that exceed ten percent (10%) lower explosive limit (LEL). Vapors for petroleum or petroleum constituents are detected in an inhabitable building in levels greater than long term, riskbased exposure for contaminants of concern. [Contact the IDEM project manager for guidance] Petroleum or petroleum constituents are detected in a drinking water well at or above maximum contamination levels (MCLs) or RISC residential groundwater cleanup objectives at the point of compliance (sampling point) or at the tap. [Reference 327 IAC 8-2-5]

1.B

1.C

CATEGORY 2 CRITERIA
If the site does no qualify as Category 1 and any of the following criteria apply, the site is prioritized in Category 2

Not Applicable

2.A

Petroleum or petroleum constituents are detected in free phase in a thickness of at least one (1) foot in any one (1) well, or at least one (1) inch in two (2) or more wells where the wells are at least twenty (20) feet apart, provided that the wells are not screened in the UST cavity backfill. Petroleum or petroleum constituents are detected in surface water above water quality standards under rules of the water pollution control board at 327 IAC 2.

2.B

CATEGORY 3 CRITERIA
If the site does no qualify as Category 2 and any of the following criteria apply, the site is prioritized in Category 3

Not Applicable

3.A

Petroleum or petroleum constituents are detected off-site in groundwater at concentrations exceeding RISC Residential Default Closure Levels (RDCLs). Petroleum or petroleum constituents are detected off-site in soil at concentrations exceeding RISC Residential Default Closure Levels (RDCLs). Petroleum or petroleum constituents are present in free phase in a thickness of at least one-sixteenth (1/16) inch in any well. Petroleum or petroleum constituents, attributable to a gasoline release, are detected in the groundwater at concentrations exceeding RISC Default Closure Levels. For the purpose of this clause, gasoline is defined as set forth in 45 IAC 12-1-7.

3.B 3.C 3.D

CATEGORY 4 CRITERIA
If the site does no qualify as Category 3 and any of the following criteria apply, the site is prioritized in Category 4

Not Applicable

4.A

Petroleum or petroleum constituents are detected in on-site groundwater at concentrations exceeding RISC Industrial Default Closure Levels (IDCLs) in two (2) or more wells, where the wells are at least twenty (20) feet apart, where neither well is screened in the UST cavity backfill. Petroleum or petroleum constituents are detected in on-site soil at concentrations exceeding RISC Industrial Default Closure Levels (IDCLs) in at least two (2) boring holes at least twenty (20) feet apart.

4.B

CATEGORY 5 CRITERIA
5.A A release that does not qualify as a Category 1, 2, 3, or 4 will be considered a Category 5 release.

SITE CATEGORY FOR CLAIMS PRIORITIZATION
NAME OF IDEM PROJECT MANAGER RE-CATEGORIZING THE SITE [FOR IDEM USE ONLY] DATE (MM / DD / YYYY)