Free 51955.pdf - Indiana

SCOPE OF WORK
State Form 51955 (R / 12-08) Pursuant to 328 IAC 1-3-3(a)(1)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF LAND QUALITY EXCESS LIABILITY TRUST FUND Telephone: (317) 234-0990 Fax number: (317) 234-0428

INSTRUCTIONS:

1. This form must be included for all proposed corrective actions submitted after September 29, 2004, [328 IAC 1-3-3(a)(1)] and should be included with technical documents related to the below referenced phases. 2. Detail each proposed activity on a separate line and provide a detailed description of each in the appropriate field. 3. Table 1 is to provide a detailed breakdown of proposed work activities utilizing the Activity Code Classification Key below. Table 2 and Table 3 are to provide detailed technical specifications for proposed wells and borings along with detailed specifications of proposed pilot studies and/or remedial systems.

NOTE:

This form does not constitute pre-approval of corrective action related costs, as provided for in 328 IAC 1-3-1.6.

SUBMIT COMPLETED FORM TO:

Indiana Department of Environmental Management Facility ID Number: Attention: ELTF Section 100 North Senate Avenue Incident Number: Indianapolis, IN 462042251 RP Name: Site Name: RP Address: Site Address: Consultant: ) RP Phone: ( ) Consultant Phone: ( Contact Name: [RP = Responsible Party]

Phase Categorization
Check only one Phase below: Site Characterization / FSI FSI / CAP Development



PreCAP Approval Monitoring CAP Addendum



CAP Implementation Site Closure



Activity Code Classification Key Please use the codes listed below when filling in the form:
A. Office Activities / Report Generation Labor A010 Supplies & Materials A020 B. Analytical Ground Water Subsurface Soil Surface Water Surface Soil Air Other B010 B020 B030 B040 B050 B060 C. Site Activities Labor Equipment Rental Subcontractor Labor Materials Other Disposal Permits Site Prep / Demolition Site Restoration


C010 C020 C031 C032 C033 C040 C050 C060 C070

Supplies Other

C080 C090

Site Investigation Specifications (see TABLE 2) Remediation Technical Specifications (see TABLE 3)
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LUST Incident number:




TABLE 1 Proposed Scope of Work Details Proposed Units Activity Code
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Unit Type

Activity and Detailed Description

IDEM Adjusted Units

LUST Incident number:




TABLE 1 ­ continued ­ Proposed Scope of Work Details Proposed Units IDEM Adjusted Units TABLE 2 Proposed Well and Soil Boring Specifications Type Boring / Well [monitoring or extraction] Depth Total Range Footage (feet) (feet)
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Unit Type

Code

Activity and Detailed Description

Number Proposed

Details

IDEM Adjusted Units

LUST Incident number:




TABLE 3 Proposed Remediation Technical Specifications I. Proposed Pilot Study Specifications Type:
[see below]

MNA


ORCs

Pump & Treat

SVE / AS

VER

EFR

DPE/ MPE

Other: Direct Push Equipment Submersible Pump Other: Vacuum Truck Air Compressor Other: Vacuum Pump / Blower Other: Other:

Equipment:


Liquid Ring Pump

II. Proposed Remedial System Specifications [check / fill out all that apply] Monitored Natural Attenuation (MNA) Sampling for MNA Parameters: Number of Monitoring Wells: Oxygen Releasing Compounds (ORCs) Number of Injection Points: Total Pounds of ORCs: Number of Injection Events: Pump and Treat Number of Recovery Wells: Number of Submersible Pumps: Number of Air Strippers: Number of Carbon Vessels (GAC): Number of Transfer Pumps: Number of Bag/Sediment Filters: Number of SVE Points: Number of AS Points: Number of Blowers/Vacuum Pumps: Number of Air Compressors: Capacity of Knockout Tack (gallons): Radius of Influence (ROI) in Feet: Other:


Vacuum Enhanced Recovery (VER) No Number of SVE/Recovery Wells: Number of Submersible Pumps: Number of Blowers/Vacuum Pumps: Number of Air Strippers:


Yes

Yes No



Number of Carbon Vessels (GAC): Number of Transfer Pumps: Capacity of Knockout Tank (gallons): Number of Bag/Sediment Filters: Enhanced Fluid Recovery (EFR) LPH Present in Extraction Wells? Number of Extraction Points: Number of Approved Events:



Capacity of Knockout Tank (gallons):

Dual or Multi Phase Recovery (DPE / MPE) Number of Extraction Points: Number of Liquid Ring Pumps (LRPs): Number of Air Strippers: Number of Carbon Vessels (GAC): Number of Transfer Pumps: Capacity of Knockout Tank (gallons): Number of Bag/Sediment Filters: Excavation / Trenching

Soil Vapor Extraction / Air Sparge (SVE / AS)

Number of Cubic Yards: Number of Tons (yds3 * 1.36): Depth of Excavation: feet Linear Footage of Trenching: feet


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