Free 47271.pdf - Indiana

Voluntary Remediation Program Application
State Form 47271 (R3/6-08) Approved by State Board Accounts, 2008

Indiana Department of Environmental Management INSTRUCTIONS

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Cashier's Office, Mail Code 50-10C 100 N. Senate Ave. Indianapolis, IN 46204

This application form shall be used to apply to the Voluntary Remediation Program pursuant to Indiana Code 13-25-5-2. When completed, please return this form and support documents to the address given in the box above.

CONFIDENTIAL
Project Number: 6| | | | | | | VRP Account #: 2680-110000-421400

Pursuant to Indiana Code 13-25-5-2, this application to the Voluntary Remediation Program (VRP) will remain confidential until the Voluntary Remediation Agreement (VRA) is signed by both parties. Neither this application nor any information which comes from this application will be made available to the public until the VRA is signed. However, any material submitted to or generated by the VRP including this application will be considered IDEM public record after the VRA is signed.

Section 1 - VRP Project Information
Applicant Billing Contact Voluntary Remediation Applicant
Applicant Name:
Name to appear on the Covenant Not To Sue

(IDEM's cost recovery invoices will be mailed to the individual/entity identified. The application will not be complete without this information) Billed Company:

Contact Name: Mailing Address: City, State, ZIP: Phone & Fax: E-Mail:

Contact Name: Mailing Address: City, State, ZIP: Phone & Fax: Federal Tax ID
(Required)

VRP Project Name and Location
Facility Name: Site Address: City: ZIP: County: EPA ID Number: Company: Contact Person: Mailing Address: City, State, ZIP: Phone & Fax: E-Mail:

Applicant's Registered Agent
or person accepting legal service if not a corporation

Applicable Facility Standard Industry Code(s) & Description(s): SIC Number: ________________ Description:_______________________________________________________________________________________________ *Please provide information on an additional page if there are not enough spaces for entries. Anticipated Future Facility Use: () () () Residential Non-Residential Currently Undetermined Current Site Status (Check all that apply) Undergoing Property Transfer () Active Operations Commercial/Industrial () () Recreational ________Years (Current Operation) Years of Current Facility Operation:

() Unknown

_________Total years site has been in use (Current and Historic)

() () ()

Inactive Operations Residential

Official State Use Only Date Stamp

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Other IDEM Offices: Does this site have a previous history with the Voluntary Remediation Program? () No application) () Yes (if yes, please attach appropriate page from Section 3 of this

Has a spill for this site been reported to IDEM's Emergency Response/Remedial Response Program? () No () Yes (if yes, please provide the incident number below and attach the appropriate page from Section 3 of this application)

Please be advised that if an appropriate remedial response is not completed in the Voluntary Remediation Program, IDEM will refer the site to the appropriate remedial program to determine if further action is required.
Emergency Response/ Remedial Response Program incident number_________________________

Is this application the result of a referral from, or under the jurisdiction of, another IDEM office? () () () () () () () () () Yes (If yes, indicate which office and complete the appropriate page in Section 3.) () No

Brownfields Program RCRA / Corrective Action Leaking Underground Storage Tanks (LUST) / Underground Storage Tanks (UST) State Cleanup Section Office of Enforcement Office of Solid Waste (Landfills) Site Investigations (SI) Other Office: Office: Incident# (if applicable) Phone #:____________________________________ Project Remediation Status: () None () Ongoing () Complete

IDEM Contact Name:_____________________________ Contaminant Source Size (defined to IDEM RISC Residential Closure Levels): () Currently Undetermined () less than or equal to 0.50 acre () greater than 0.50 acre

Project Investigation Status:

() Ongoing () Complete

Known or Anticipated VRP Project Hazards/Conditions: () None () Reactive Materials () Infectious Materials () Radioactivity () Confined Spaces () Explosive Conditions

() Known Off-Site Contamination

() Other: ________________________________________________ Property Ownership

Documents Anticipated To Be Submitted for VRP Review: (Please check all that are expected) Do you own this property? () Phase II Investigation Work Plan () Phase II Investigation Report

() Yes

() No (If no, answer next question)

If not, name of the current owner ________________________________________ and, do you have legal access rights to this property from that owner? (X) Remediation Work Plan (VRP requirement) () Yes () Site Specific Risk Assessment (X) Remediation Completion Report (VRP requirement) () No

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Local Drinking Water Supply: Surface Municipal Private/Residential () ()

Local Drinking Water Supply Distance From Facility: Groundwater ____________ Feet () Is the site in a designated Wellhead Protection Area? () Yes () No () Is the site in a designated Sole Source Aquifer? () Yes () No ________________ Mile(s)

Local Surface Water Bodies Near Facility: (check closest) () Wetland(s) () Stream(s) () River(s) () Lake(s) () Pond(s)

Local Surface Water Bodies Distance From Facility: ____________ Feet ________________ Mile(s)

On- site Water Supply and Usage: () () () Well(s) Municipal () Drinking () Drinking () Production () Production () Agricultural () Both () Both

Site Specific Depth to Groundwater: ______________ feet () Currently Unknown () Unknown () W

Site Specific Principal Groundwater Flow Direction: () NW () N () NE () E () SE () S () SW

No Water at Site

Site History and Conditions
Facility Operational History:

Source Area/Contaminant Information: Provide a description of the known or suspected source area(s) that will be addressed in this VRP project by answering the questions below. This project must address all constituents and media related to each source identified, including offsite contamination. Only the actual source area(s) on the property and the area that is appropriately investigated under RISC will receive the liability protection of a Covenant Not To Sue. If multiple source areas are being addressed in this project, this page may be duplicated to provide the information requested for each source area. What is the known or suspected source of contamination that will be the subject of this VRP project?

Briefly describe any efforts undertaken to remediate contamination.

Soil Impacts: What contaminants have been detected in soil, and what is the maximum concentration (or range of concentrations) detected? If several contaminants within the same class have been detected (VOCs, SVOCs, etc.), list the primary contaminants of concern within each class. A map showing boring locations is required in Attachment A.

Has the extent of soil contamination been defined to RISC Residential Closure levels? Yes ( ) No ( ) Groundwater Impacts: What contaminants have been detected in ground water and what is the maximum concentration (or range of concentrations) detected? If several contaminants within the same class have been detected (VOCs, SVOCs, etc.), list the primary contaminants of concern within each class. A map showing groundwater sample locations is required in Attachment A.

Has the extent of ground water contamination been defined to RISC Residential Closure levels? Yes ( ) No ( ) Page 3 of 19

Is ground water contamination known or suspected to have migrated offsite? Yes ( ) No ( ) Uncertain ( ) Describe any efforts to evaluate offsite contamination.

Are contaminants from this release believed to pose an imminent or substantial threat to human health or the environment? Yes ( ) No ( ) If the answer is Yes, describe below and take immediate steps to mitigate the release.

Does contamination from the site have the potential for human exposure? Possible pathways include: drinking water wells, vapor intrusion into occupiable structures, and contaminated surface soil in occupied locations. Yes ( ) No ( ) Uncertain ( ) If yes, describe.

Does contamination from the site have the potential for ecological exposure? Yes ( ) No ( ) Uncertain ( ) Is it likely contamination has extended to surface water, sediments, wetlands, karst bedrock, or any other sensitive area? Yes ( ) No ( ) Uncertain ( ) If you answered yes to either question, describe potential exposure.

Past Spill History (If no previously reported incidents have occurred, please mark here () ):

Geologic Information:

Hydrogeologic Information:

Additional Environmental Information: () Previous Facility Studies (please include Title, Author & Date):

() Other (please include Title, Author, and Date): ____________________________________________________________________________________________________________________________ () U.S. Geological Survey () Regulatory Reporting () State Reports () Soil Conservation Service () Other Governmental Agencies () Other: Page 4 of 19 () Past Voluntary Site Specific Data Collection

Section 2 - Statement of Certification
Pursuant to Indiana Code 13-25-5-2, this application to the Voluntary Remediation Program (VRP) will remain confidential until the Voluntary Remediation Agreement (VRA) is signed by both parties. Neither this application, nor any information which comes in addition to this application, will be made available to the public until the VRA is signed. However, material submitted to or generated by the VRP will be considered IDEM public record after the VRA is signed.

I, _____________________________________________________, certify that this document and all attachments were prepared under my direction (Print or Type Name of Applicant) or supervision by qualified personnel. Based on my inquiry of the persons who gathered the information, it is, to the best of my knowledge, true, accurate, and complete. I further certify that I am authorized to submit this information. ______________________________________________________________________________________________________________________________ Applicant's Signature (see application instructions for appropriate signatory) Date By signing this Application, the Applicant understands and agrees that the entire VRP process must be completed to IDEMs satisfaction in order to remain an active participant in the VRP. Therefore, if IDEM determines that the Applicant has not made good faith efforts to execute the Voluntary Remediation Agreement, or fails to provide the required documents and information to IDEM for evaluation of the site and work done to determine whether or not the Remediation Work Plan has been successfully completed, the Voluntary Remediation Agreement will terminate.

Attachment Information: This application will not be considered complete, and may be rejected, unless the following Attachments are included: Attachment A: Please attach a detailed site map illustrating identified area(s) targeted for VRP efforts. For an explanation of a detailed site map, please see Attachment A instructions. Attachment B: Attachment B: Legal Description--A certified copy of the warranty deed with a legal description and the property owner's name. The deed must identify the owner AND the name on the deed MUST match the name of the current owner. If the names do not match, additional information must be provided to clarify ownership. For example, if a corporation owns the property, then proof that the corporation on the deed is the predecessor to the current corporation must be submitted. If the deed does not adequately describe the property due to the occurrence of multiple land transactions, a new legal description MUST be prepared by a professional land surveyor and the professional seal/certification must be stamped on the new legal description. Attachment C: Please check Application Form Instructions and provide the pertinent Facility Universal Transverse Mercator (UTM) coordinates information and include as Attachment C. Attachment D: Additional pages from Section 3 (if applicable).

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Section 3- Application Attachment Pages CO-APPLICANT ATTACHMENT If more than one party is applying to the VRP, use this attachment to provide information about co-applicant(s). Please be advised that at the successful conclusion of this project, only applicants to the VRP will receive the Certificate of Completion and Covenant Not to Sue.
Pursuant to Indiana Code 13-25-5-2, this application to the Voluntary Remediation Program (VRP) will remain confidential until the Voluntary Remediation Agreement (VRA) is signed by both parties. Neither this application, nor any information which comes in addition to this application, will be made available to the public until the VRA is signed. However, material submitted to or generated by the VRP will be considered IDEM public record after the VRA is signed.

Section 1 - VRP Facility Declarations
Voluntary Remediation Applicant
Applicant Name: Contact Person: Mailing Address: City, State, ZIP: Phone & Fax: E-Mail: Company: Contact Person: Mailing Address: City, State, ZIP: Phone & Fax: E-Mail:

Applicant's Registered Agent
or person accepting service if not a corporation

I, ___________________________________________________________, certify that this document and all attachments were prepared under my direction (Print or Type Name of Applicant) or supervision by qualified personnel. Based on my inquiry of the persons who gathered the information, it is, to the best of my knowledge, true, accurate, and complete. I further certify that I am authorized to submit this information. ______________________________________________________________________________________________________________________________ Applicant's Signature (see application instructions for appropriate signatory) Date By signing this Application, the Applicant understands and agrees that the entire VRP process must be completed to IDEMs satisfaction in order to remain an active participant in the VRP. Therefore, if IDEM determines that the Applicant has not made good faith efforts to execute the Voluntary Remediation Agreement, or fails to provide the required documents and information to IDEM for evaluation of the site and work done to determine whether or not the Remediation Work Plan has been successfully completed, the Voluntary Remediation Agreement will terminate.

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VOLUNTARY REMEDIATION PROGRAM 1. Does this site currently have any other VRP applications submitted/approved for this same site? () Yes If yes, VRP Project Number(s)___________________________________ VRP Project Manager(s):___________________________________ () No

2. Was this site the subject of a VRP project at anytime in the past?

() Yes

() No

If yes, VRP Project Number(s)___________________________________ VRP Project Manager(s):___________________________________ 3. Please provide details below explaining why another application for this same site is/was necessary: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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BROWNFIELDS PROGRAM 1. Is this site currently in Indiana's Brownfields Program? () Yes () No () Yes () No () No

2. Has this site previously been in Indiana's Brownfields Program? 3. Is this Brownfields site to be addressed in the VRP? () Yes

4. If this site is to be addressed in the VRP, has the Brownfields Project Manager been notified in writing? () Yes (if yes, please attach copy of the letter) () No () No

5. Is this site going to make use of Brownfields money (grants, loans, assessment money, etc.)? () Yes 6. What is the Brownfield Project Number (if applicable)? _____________________________

7. Who is the Brownfield contact person and their phone number? Brownfield Contact: __________________________________ Phone Number: __________________________________ 8. Please provide summary of the Brownfields issues below: (If applicable) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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RCRA / CORRECTIVE ACTION 1. Are you interested in addressing RCRA Corrective Action Requirements for this source area through this VRP Project? () Yes () No 2. Has the RCRA Corrective Action Project Manager been notified in writing that a VRP application has been submitted to address this contamination? () Yes () No 3. What is the facility EPA ID number? _____________________________ 4. What is the date of Notification of Hazardous Waste Activity? _____________________ 5. Have you submitted a RCRA Part A application for Interim Status? () Yes () No

If Yes, date: ___________________________ 6. Have you lost Interim Status or gone through an EPA Policy 121 closure for Mistaken and Protective Filings? () Yes () No If Yes, please attach a copy of the letter. 7. Does this facility have a RCRA Part B Operating Permit? () Yes () No

If Yes, date issued: ______________________ Expiration date: __________________ 8. Have any permitted units undergone closure? () Yes () No () Yes () No () Yes () No

Were those units cleaned closed?

Were any land-based units closed in place?

If Yes, check all boxes that are applicable: () Lined (describe type of liner-_______________________) () Unlined () Capped (describe type of cap-__________________________) () Not Capped 9. Is this facility currently under any enforcement action, Agreed Order, Commissioner's Order, or any other type of required action by any government agency? () Yes (if Yes, describe below) () No _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

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EMERGENCY RESPONSE / REMEDIAL RESPONSE PROGRAM 1. Has this spill / release been reported to IDEM? () Yes () No

If yes, what is the Spill Incident Number(s): ___________________________________________ IDEM contact person(s): ___________________________________________ Contact's telephone number: _________________________________________ 2. Is this spill / release to be addressed in the VRP? () Yes () No

3. Has the IDEM contact person been notified in writing that this spill / release will be addressed in the VRP? () Yes (if yes, please attach copy of the letter) () No

4. If this spill / release is to be addressed in the VRP, please provide a summary of the spill / release below: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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LEAKING UNDERGROUND STORAGE TANKS (LUST) & UNDERGROUND STORAGE TANKS (UST) 1. Is the UST(s) the source of the contamination to be addressed as part of the VRP? 2. Did / Does the UST contain petroleum products? 3. Is the UST regulated? () Yes () No () Yes () No () N/A () Yes () No () Yes () No

4. Has the regulated UST been registered with IDEM?

If yes, indicate the UST Facility I.D. Number: _________________________ 5. Has a UST petroleum release ever been reported to IDEM? () Yes () No () N/A

If yes, indicate the LUST Incident Number: ___________________________ 6. Has the LUST section been notified in writing that you are applying to the VRP? () Yes (if yes, please attach copy of the letter) () No

7. Do you intend to apply for Excess Liability Trust Fund (ELTF) reimbursement with respect to this cleanup? () Yes () No () N/A

8. If you have already applied for ELTF reimbursement, indicate ELTF number. __________________________ 9. Please provide a summary of the site issues to be addressed below:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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STATE CLEANUP SECTION 1. Is this site under an Agreed Order or Commissioner Order with IDEM? () Yes () No

2. What is the State Cleanup Project I.D. Number? ___________________________ 3. Is this State Cleanup site to be addressed in the VRP? () Yes () No

4. If this site is to be addressed in the VRP, has the State Cleanup Project Manager been notified in writing? () Yes (if yes, please attach copy of the letter) () No

5. Who is the State Cleanup Project Manager and what is their telephone number? Project Manager: _________________________________ Telephone Number: _______________________________ 6. Provide a summary of the site issues below: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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OFFICE OF ENFORCEMENT (OE) 1. Is the site / facility that is subject to enforcement to be addressed in the VRP? () Yes () No (if No, skip all other questions on this page)

2. Is the site under any of the following types of enforcement: Formal () () () Notice of Violation Agreed Order Commissioner's Order () Informal Violation Letter

3. What is the Case Number(s)? _______________________________________________ 4. Who is the OE contact person and what is their telephone number? Contact Name: ________________________________________ Telephone Number: ____________________________________ 5. If this enforcement site is to be addressed in the VRP, has the OE contact person been notified in writing? () Yes (if yes, please attach copy of the letter) 6. Provide a summary of the site issues to be addressed below: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ () No

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OFFICE OF SOLID WASTE (Landfills and Processing Facilities) (Due to IDEM requirements, it is unlikely that facilities with significant amounts of waste left in place will receive a Covenant Not to Sue as a closure mechanism) 1. 2. Is this a solid waste landfill Site? Is this landfill active? () Yes () Yes () No () No (If No, skip to question #7)

If Yes, what year did the landfill begin accepting waste? ________________________ 3. Is this landfill inactive? () Yes () No

If Yes, what year did the landfill begin accepting waste? ________________________ If Yes, what year did the landfill cease accepting waste? ________________________ 4. Is the landfill lined? () Yes () No

If Yes, what type of liner does it have? _________________________________________ 5. Is the landfill capped? () Yes () No

If Yes, what material(s) is the cap constructed of? _______________________________ 6. 7. Were hazardous or petroleum constituents placed into the landfill at any time? () Yes () No

What type of solid waste site is it and what does it contain? ________________________________ ________________________________________________________________________________ ________________________________________________________________________________

8.

Is this a solid waste permitted facility?

() Yes (If Yes, provide following information)

() No

What is the facility Identification number: __________________________ Permit type:_________________________________________________ Permit number ______________________________________________ Date issued: ________________________________________________ Date it expires:______________________________________________ IDEM Solid Waste Contact (Name and Telephone number)____________________________________ 9. Is this facility being required to conduct a cleanup by or under an enforcement action with any government agency? () Yes () No If Yes, provide details: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 10. Has the solid waste contact person been notified in writing that a VRP application for this facility has been submitted? () Yes (If Yes, attach a copy of this letter) () No

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SITE INVESTIGATIONS (SI) 1. 2. 3. 4. 5. 6. Is this site currently in IDEM's Site Investigation Program? () Yes () No () Yes () No

Has this site previously been in IDEM's Site Investigation Program? Is this Site Investigation issue to be addressed in VRP? () Yes

() No

If this site is to be addressed in the VRP, has the Site Investigation Project Manager been notified in writing? () Yes (if yes, please attach copy of the letter) () No What is the EPA ID Number for this site (if applicable)? _________________________________ What is the name and address of this site? ____________________________________ ____________________________________ ____________________________________

7.

Who is the IDEM contact person and their telephone number? IDEM Contact: _____________________________________ IDEM Telephone Number: ____________________________

8.

Please provide summary of the Site Investigation issues below: (If applicable) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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Indiana Department of Environmental Management Voluntary Remediation Program Application Instructions
How Is the Information I Submit Used? The information provided on the application is used to determine an Applicant's eligibility for participation in the Voluntary Remediation Program (VRP). It also serves as an initial summary of site conditions, defines the scope of the investigation/remediation, and identifies the release(s) targeted for remediation efforts. The Application assumes that the applicants have already done an Environmental Site Assessment or similar investigation. These instructions pertain to the Voluntary Remediation Program Application Form 47271 (R3/ 6-08). The VRP application must be completed providing all requested information as currently known to the applicant. Failure to provide the requested information is grounds for application rejection. The application and its information will be confidential and not released to the public until and unless the Voluntary Remediation Agreement (VRA) is signed. Once the VRA is signed, the application and any other information submitted will be made available to the public. The application may be filled out by hand, typewriter or word processor. At this time, the VRP cannot accept applications online due to the signature requirement. Application Fee Indiana Code 13-25-5-2 establishes a $1,000.00 fee that must be submitted along with the completed Application Form. However, a political subdivision is not required to submit an application fee. The VRP cannot process the application until a program applicant submits the fee. Please make checks payable to the Voluntary Remediation Program Fund and reference Account # 2680-110000-421400 in the check memo blank. Where Should I Send My Application? Send a brief cover letter, two (2) copies of the completed Application Form (both with original signature) and the application fee to: Indiana Department of Environmental Management Cashier's Office ­ Mail Code 50-10C 100 N. Senate Ave. Indianapolis, IN 46204 (317) 233-0604 If you require assistance in filling out the application, please contact the Voluntary Remediation Program at (317) 234-0966 or (800) 451-6027. What Happens to the Application? Upon receipt, the Cashier's Office will process the application fee. They will generate and provide a receipt to the applicant, and assign a unique project number to the application. The application is then sent to the VRP to begin an internal enforcement check. This enforcement check consists of contacting other IDEM programs and inquiring about the proposed VRP project and any enforcement actions which may be pending. If any of the following apply to the proposed VRP project, then the application may be rejected: · A state or federal enforcement action concerning the proposed cleanup is pending; · A federal grant compels IDEM to take enforcement action; · Conditions at the site are considered an imminent and substantial threat to human health or the environment; · The application is incomplete. How Long Will it Take to Process My Application? VRP has 30 days to determine the eligibility of an applicant. Incomplete applications will be returned to the applicant within 45 days of receipt with the missing information identified. After revisions, applicants may resubmit the form. Upon approval, the VRP will send a formal letter identifying the assigned VRP project manager and project number to the applicant as listed on the application.

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Voluntary Remediation Program Application Instructions Mailing Information (located in the upper right hand corner) Project Number - For IDEM Internal Use Only, please leave blank Section 1 - VRP Project Information Voluntary Remediation Applicant - The applicant is the person or group who is guiding the remedial activities at the site and will receive the Certificate of Completion and Covenant Not To Sue upon completion of remediation activities. Indicate the applicant name, contact name, mailing address, city, state, zip code, telephone number, fax number and e-mail address of the applicant. (If this site has multiple applicants, please supply a Co-Applicant Attachment page from Section 3 for each additional applicant.) Please be accurate: the Certificate of Completion and Covenant Not To Sue will be issued under the name exactly as it appears on the application form. All official correspondence from IDEM will be sent to the person identified in this section. Applicant's Billing Contact - Complete this section with the proper billing address for the applicant. This contact will receive the cost recovery invoices from IDEM for payment. The application will not be considered complete without this information. VRP Project Name and Location - This is the name and address of the facility that will be the subject of the remediation as listed in official records (Examples: Smith Chemical; Former Jones Service Station; or Metals-R-Us Waste Lagoon #2). If a precise street address is unavailable, enter a brief direction identifier, e.g., NW jct I-295 & US23. Also provide the EPA ID# in the space provided. Provide any existing facility federal identification number (EPA hazardous waste generator or CERCLIS). This should be a 9 digit number starting with IND. If unknown or does not apply, please so state. Applicant's Registered Agent or person accepting service if not a corporation - A registered agent is a corporation's agent for service of process, notice, or demand required or permitted by law to be served on the corporation. For noncorporate entities, identify the person who will accept this service on behalf of the applicant. This would not typically be the environmental consultant. Applicable Facility Standard Industry Code & Description - Identify the Standard Industrial Classification (SIC) associated with the facility's operations along with a written description (SIC Code Descriptions can be provided). Anticipated Future Facility Use ­ If known, indicate the most likely future use of the site. Years of Current Facility Operation - If known, provide the years of current facility operation. If known, provide the total years the site has been utilized by current and historic operations or activities. Check "Unknown" if years of operation are unknown. Current Site Status - Indicate the site's current operational and transactional status. Check all that apply. Official State Date Stamp- Please leave blank. Other IDEM Offices- Identify if the site in question has any current or past involvement with other IDEM offices. If yes, please fill in the corresponding attachment page(s) in Section 3 and supply as Attachment D. Contaminant Source Size - If known, indicate the horizontal source area. This information is useful for determining the level of investigative effort. Project Investigation Status - Indicate status of any site investigation related to contaminants and/or areas to be voluntarily remediated at the time of program application. Project Remediation Status - Indicate status of any site remediation related to contaminants and/or areas to be voluntarily remediated at the time of program application. Known or Anticipated VRP Project Hazards/Conditions - Mark the appropriate oval(s) to indicate the hazards posed by the VRP project, or its contaminant(s). If the VRP project or its contaminant(s) pose no unusual hazard, mark "None". Documents Anticipated To Be Submitted for VRP Review - Please indicate the anticipated documents that will be reviewed by the VRP. The requested level of VRP effort will be reflected in the VRP oversight cost estimate provided with the Voluntary Remediation Agreement. Both the Remediation Work Plan and the Remediation Completion Report are standard program documents and must be submitted by all applicants. Property Ownership- Please indicate if the applicant owns this site and if not, whether the applicant has legal access to it.
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Local Drinking Water Supply - Indicate the source(s) of local drinking water used at or closest to the facility. This must include, at a minimum, all adjoining properties and communities. Indicate whether municipal and/or private/residential water supplies. Questions about a facilities location in a Wellhead Protection Area can be sent to IDEM at: http://www.in.gov/idem/programs/water/swp/whpp/documents/proxform.pdf. Local Drinking Water Supply Distance From Facility - Please identify the distance from the facility to the previously identified closest drinking water source. Local Surface Water Bodies Near Facility - Indicate the closest type of surface water body to the facility. Local Surface Water Bodies Distance From Facility - Please identify the distance of this water body from the facility. On-Site Water Supply and Usage- Please identify the types of on-site water supply and usage. Site Specific Depth to Ground Water - Use information already gathered from previous site investigation(s). If unknown, please mark the oval. Site Specific Principle Ground Water Flow Direction - Use information already gathered from previous site investigation(s). If unknown, please mark the oval.

Site History and Conditions
Provide the following information in as much detail as space allows. Answer all questions. A lack of a response will jeopardize the application's acceptance. Facility Operational History - Indicate past operational activities associated with the facility. If known, please identify all companies, years of operation and type of operations. Source Area/Contaminant Information ­ Provide a complete description of the known or suspected source area(s) that will be addressed in this VRP project and the known impacts to each media (surface soils, subsurface soils, groundwater, sediments, and indoor air) and any impacts off-site. The VRP will only provide liability protection for the actual source area(s) on the property that are appropriately addressed under IDEM's RISC policy. The VRP will not provide "sitewide" coverage where there is no information to suggest a release (or threat of a release) has occurred on larger areas of real property. Maximum contaminant concentrations or a range of concentrations for all media must be provided. Indicate if an imminent or substantial threat resulting from the contaminants described in the application is present. If an imminent or substantial threat exists, provide an explanation and proceed with appropriate steps to mitigate the threat. Indicate if a potential ecological exposure exists. Identify all known and potential off-site contaminant migration and preferential migration pathways (utility lines, sand seams, etc.). If no off-site impacts are known, mark the oval. Provide a brief explanation of any efforts to evaluate offsite contamination. Past Spill History - Identify all past spill incidents associated with the facility that relate to the contaminant(s) targeted for this project. Please include dates and IDEM incident numbers assigned to the spill and cleanup status. If the facility has no spill history, mark the oval. Geologic Information ­ Provide basic site geologic information, at a minimum include the following items: site soil stratigraphy, lithologic descriptions or USDA soil textures, and a description of area fill or drainage improvements. Hydrogeologic Information ­ Provide basic site hydrogeologic information, at a minimum include the following items: depth to groundwater, flow direction, hydraulic conductivity, confined or un-confined conditions, porosity, and regional aquifer, etc.

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Additional Environmental Information - Please mark the ovals that identify informational resources that were used to assist in completing this application. Include report titles and dates. If additional space is necessary, please attach a bibliography as an Attachment. Section 2 - Statement of Certification Statement Of Certification - Before signing the application, please read the highlighted box. All applications must be signed and dated in ink. No signature photocopies will be accepted. Applications should be signed as follows: (1) For corporations, by a responsible corporate officer; (2) for a partnership or sole proprietorship, by a general partner or the proprietor, respectively; (3) for a municipality, state, federal, or other public agency or political subdivision, by either a principal executive office or ranking elected official. Attachment Information: Attachment Information - The application will not be considered complete unless the information asked for in the following attachments is provided. Attachment A: VRP Project Map ­ Applications must include a map of the facility with the following information: illustrated legends and compass directions; known or potential source area(s) that will be the subject of this VRP project; identified aboveground features (buildings, roadways, property lines, etc.); representative sample locations along with concentrations. Additional information to include if available; horizontal and vertical plume identification; geologic cross sections showing the water table and vertical plume identification; groundwater flow direction. If preferred, contaminant concentrations corresponding to sample locations identified on the map can be provided on a separate table. Attachment B: Legal Description - Attachment B: Legal Description--A certified copy of the warranty deed with a legal description and the property owner's name. The deed must identify the owner AND the name on the deed MUST match the name of the current owner. If the names do not match, additional information must be provided to clarify ownership. For example, if a corporation owns the property, then proof that the corporation on the deed is the predecessor to the current corporation must be submitted. If the deed does not adequately describe the property due to the occurrence of multiple land transactions, a new legal description MUST be prepared by a professional land surveyor and the professional seal/certification must be stamped on the new legal description. Attachment C: Facility UTM Coordinates - IDEM staff request that contractors, consultants and/or responsible parties submit coordinates in Universal Transverse Mercator projection (easting and northing), datum NAD83 Zone 16N for each VRP facility. All facilities are asked to provide coordinates for at least one property access point (i.e. driveway, property gate) along the property boundary. This information will be used in IDEM's Geographic Information System and is required to meet EPA's Locational Data Policy. The coordinates can be collected using: 1) Global Positioning System (GPS) mapping grade equipment, 2) GPS survey grade equipment, 3) Topographic map interpolation, or 4) traditional surveying. If GPS equipment is used, the following information must be provided by the contractor and reflected in Attachment C: 1) How the coordinates were collected (i.e. GPS); 2) Where the coordinates were collected (at common property access point - front gate); 3) Accuracy of the coordinates; 4) Date the coordinates were collected; 5) GPS Model used; 6) GPS data postprocessed (yes or no); 7) Manufacturer's GPS accuracy specifications; 8) Datum (should be NAD83); and 9) Zone (should be 16). Accuracy information should be provided for all coordinates regardless of how they are collected. This information is required to meet the Federal Spatial Data Transfer Standard (SDTS) and IDEM's Method Accuracy Description (MAD) Information Coding guidance. Attachment D: Include any additional pages required by the application from Section 3. This could include the co-applicant page(s), or any of the pages supplying information on other IDEM offices that may be connected to this site.

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