HomeMy WebLinkAboutDEP Transmittal Form for Recording the Receipt and-or Issuance of BWSC DocsA. RELEASE OR THREAT OF RELEASE LOCATION:
1. Release Name/Location Aid:REPUBLIC SERVICES FACILITY
2. Street Address:61 COMMONWEALTH AVE
3. City/Town:YARMOUTH 4. ZIP Code:026640000
B. THIS FORM IS BEING USED TO: (check all that apply)
1. Record and Attach a Notice of Responsibility or related Document: (check one)
a. Notice of Responsibility (NOR)d. Oneyear Anniversary Letter
b. Field NOR e. Retraction of an NOR
c. Notice of Obligation/Notice of Requirements
2. Record and Attach a Denial of a Release Notification Retraction
3. Record and Attach:a. Request for Access Letter b. Signed Access Agreement
4. Record and Attach a Lowerlevel Enforcement and/or Audit Related Document(s): (check all that apply)
a. Notice of Audit g. Request for Information
b. Request for Information Relating to an Audit h. Notice of Noncompliance
c. Notice of Audit Findings No Violations i. Notice of Need to Conduct Field Work
d. Notice of Audit Findings Violations without Followup j. Interim Deadline Letter
e. Notice of Audit Findings/Notice of Noncompliance
f. Interim Deadline Letter Relating to an Audit
5. Record and Attach an Executed Higherlevel Enforcement Related Document: (check one)
a. Penalty Assessment Notice e. Administrative Consent Order with Penalty
b. Unilateral Administrative Ordery f. Amendment of a Higherlevel Enforcement Document
c. Demand Notice g. Notice of Response Action
d. Administrative Consent Order h. Notice of Intent to Mobilize
6. Record and Attach MassDEP Initiated Response Action (RA) related Document and/or Activity: (check one)
a. Technical Screen Audit (L1)c. Audit Inspection (L2)e. Comprehensive Audit (L3)
b. Written Plan Approval d. Written Plan Denial f. Audit Memorandum
g. Other RA related Document and/or Activity Specify:
h. A Submittal that has been Invalidated or Terminated by
MassDEP
Specify:
7. Select Response Actions Associated with Activity checked in B6: (check all that apply)
a. Release Notification d. Downgradient Property Status (DPS)
b. Immediate Response Action (IRA)e. Utilityrelated Abatement Measure (URAM)
c. Release Abatement Measure (RAM)f. Tier Classification /Phase I
7. Select Response Actions Associated with Activity checked in B6 (cont.): (check all that apply)
g. Comprehensive Response Actions i. Permanent or Temporary Solution
h. Activity and Use Limitation (AUL)j. Other Response Actions Describe:
8. Record and Attach any other MassDEP Document Specify:
9. Record Date of Document(s) and/or Activity(ies) from B1 thru B8:8/17/2020
(mm/dd/yyyy)
Check here to confirm that these are final document(s) intended for public viewing (do not use for internal only documents).
10. Record and Attach a Special Project Activity or Submittal: (check all that apply)
a. Special Project Permit b. Special Project Extension
c. Other Special Project Activity Describe:
11. Attach any other Submittal received by MassDEP Specify:
12. Record Date of Activity(ies) and/or Submittal from B10 or B11:
(mm/dd/yyyy)
13. Record Additional Information:
C. PRP OR OTHER PERSON ASSOCIATED WITH DOCUMENT:
1. Check all that apply:a. change in contact name b. change of address c. new person associated with release
2. Name of Organization:
3. Contact First Name:KURT E 4. Last Name:KLAGES
5. Street:83 LEADMINE LN 6. Title:
7. City/Town:FISKDALE 8. State:MA 9. ZIP Code:015180000
10. Telephone:11. Ext:12. EMail:
13. Relationship of Person to Release:PRP OTHER c. Type(e.g. Current Owner):Licensed Site Professional
14. No Person associated with activity or document specified in Section B.
D. MassDEP STAFF AND FORM PREPARER:
1. MassDEP Staff:MURPHY BOB b. Check here, if Unassigned. (or staff name not applicable)
2. Preparer Signature:ROBERT MURPHY 3. Date :8/17/2020
(mm/dd/yyyy)
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup
TRANSMITTAL FORM FOR RECORDING THE RECEIPT
AND/OR ISSUANCE OF BWSC DOCUMENTS
BWSC 128
Release Tracking Number
4 28368
Revised: 01/31/2014 Page 1 of 2
Revised: 01/31/2014 Page 2 of 2
A. RELEASE OR THREAT OF RELEASE LOCATION:1. Release Name/Location Aid:REPUBLIC SERVICES FACILITY2. Street Address:61 COMMONWEALTH AVE3. City/Town:YARMOUTH 4. ZIP Code:026640000B. THIS FORM IS BEING USED TO: (check all that apply)1. Record and Attach a Notice of Responsibility or related Document: (check one)a. Notice of Responsibility (NOR)d. Oneyear Anniversary Letterb. Field NOR e. Retraction of an NORc. Notice of Obligation/Notice of Requirements2. Record and Attach a Denial of a Release Notification Retraction3. Record and Attach:a. Request for Access Letter b. Signed Access Agreement4. Record and Attach a Lowerlevel Enforcement and/or Audit Related Document(s): (check all that apply)a. Notice of Audit g. Request for Informationb. Request for Information Relating to an Audit h. Notice of Noncompliancec. Notice of Audit Findings No Violations i. Notice of Need to Conduct Field Workd. Notice of Audit Findings Violations without Followup j. Interim Deadline Lettere. Notice of Audit Findings/Notice of Noncompliancef. Interim Deadline Letter Relating to an Audit5. Record and Attach an Executed Higherlevel Enforcement Related Document: (check one)a. Penalty Assessment Notice e. Administrative Consent Order with Penaltyb. Unilateral Administrative Ordery f. Amendment of a Higherlevel Enforcement Documentc. Demand Notice g. Notice of Response Actiond. Administrative Consent Order h. Notice of Intent to Mobilize6. Record and Attach MassDEP Initiated Response Action (RA) related Document and/or Activity: (check one)a. Technical Screen Audit (L1)c. Audit Inspection (L2)e. Comprehensive Audit (L3)b. Written Plan Approval d. Written Plan Denial f. Audit Memorandumg. Other RA related Document and/or Activity Specify:h. A Submittal that has been Invalidated or Terminated byMassDEP Specify:7. Select Response Actions Associated with Activity checked in B6: (check all that apply)
a. Release Notification d. Downgradient Property Status (DPS)
b. Immediate Response Action (IRA)e. Utilityrelated Abatement Measure (URAM)
c. Release Abatement Measure (RAM)f. Tier Classification /Phase I
7. Select Response Actions Associated with Activity checked in B6 (cont.): (check all that apply)
g. Comprehensive Response Actions i. Permanent or Temporary Solution
h. Activity and Use Limitation (AUL)j. Other Response Actions Describe:
8. Record and Attach any other MassDEP Document Specify:
9. Record Date of Document(s) and/or Activity(ies) from B1 thru B8:8/17/2020
(mm/dd/yyyy)
Check here to confirm that these are final document(s) intended for public viewing (do not use for internal only documents).
10. Record and Attach a Special Project Activity or Submittal: (check all that apply)
a. Special Project Permit b. Special Project Extension
c. Other Special Project Activity Describe:
11. Attach any other Submittal received by MassDEP Specify:
12. Record Date of Activity(ies) and/or Submittal from B10 or B11:
(mm/dd/yyyy)
13. Record Additional Information:
C. PRP OR OTHER PERSON ASSOCIATED WITH DOCUMENT:
1. Check all that apply:a. change in contact name b. change of address c. new person associated with release
2. Name of Organization:
3. Contact First Name:KURT E 4. Last Name:KLAGES
5. Street:83 LEADMINE LN 6. Title:
7. City/Town:FISKDALE 8. State:MA 9. ZIP Code:015180000
10. Telephone:11. Ext:12. EMail:
13. Relationship of Person to Release:PRP OTHER c. Type(e.g. Current Owner):Licensed Site Professional
14. No Person associated with activity or document specified in Section B.
D. MassDEP STAFF AND FORM PREPARER:
1. MassDEP Staff:MURPHY BOB b. Check here, if Unassigned. (or staff name not applicable)
2. Preparer Signature:ROBERT MURPHY 3. Date :8/17/2020
(mm/dd/yyyy)
Massachusetts Department of Environmental ProtectionBureau of Waste Site CleanupTRANSMITTAL FORM FOR RECORDING THE RECEIPT AND/OR ISSUANCE OF BWSC DOCUMENTS BWSC 128Release Tracking Number428368
Revised: 01/31/2014 Page 1 of 2
Revised: 01/31/2014 Page 2 of 2
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup
TRANSMITTAL FORM FOR RECORDING THE RECEIPT
AND/OR ISSUANCE OF BWSC DOCUMENTS
BWSC 128
Release Tracking Number
4 28368