Approval Request or Notice Transmittal - Connecticut

1 Date Stamp (DEEP Use Only) Bureau of Water Protection and Land Reuse Remediation Division Approval Request or Notice Transmittal Form In accordance with RCSA Section 22a-133k-1(f) Any person requesting a variance or any other Approval by the Commissioner, pursuant to sections 22a-133k-1 through 22a-133k-3 of the Regulations of Connecticut State Agencies [RSRs], or submitting any required Notice to the Commissioner pursuant to the RSRs, shall submit such Request or Notice on this Approval Request or Notice Transmittal Form. Attach all information required by the applicable provision(s) in the RSRs for each type of Request or Notice submitted under this Transmittal form.

2 All sections of this form must be filled out, as applicable. Note: the application of some RSR provisions necessitate consent from the property owner. Confirmation of this consent will be expected in the specific application package. Groundwater Classification: Remediation ID No. (Rem#): Site Identification Site Name: Site Address: City/Town: State: Zip Code: Transfer Act (pursuant to CGS section 22a-134a) DEEP Enforcement / Order: Voluntary Remediation (pursuant to CGS section 22a-133x or 22a-133y) Other (specify): Printed name & signature of person submitting this Request or Notice Name of signatory for Certifying Party or Name of Property Owner (as applicable) (print or type) Name and license # of LEP (print or type).

3 Document Information (list document which contains Request (s) or Notice (s)) DOCUMENT DATED PREPARED BY Number of Approvals requested: Page/Section in Document: Page/Section in Document: Number of Notices Included: DEP-REMED-PTP-ARN 1 of 3 Rev. Approval Request or Notice Form (continued) Rem#: Approvals Requested with this Transmittal Check each box that applies to the Approval (s) requested with this Transmittal . Approvals Required by the Remediation Standard Regulations (RSRs) RSR Section References STANDARDS FOR SOIL REMEDIATION Intent to use an existing permanent structure to prevent migration of pollutants 22a-133k-1(a)(18)(A)(ii) Additional Polluting Substances - Direct Exposure Criteria 22a-133k-2(b)(5) Alternative Direct Exposure Criteria 22a-133k-2(d)(1) & (2) Alternative Direct Exposure Criteria for PCBs 22a-133k-2(d)(1) &(7) Alternative Analytical Method Direct Exposure Criteria 22a-133k-2(e)(1)

4 Inapplicability of Pollutant Mobility Criteria (80% Infiltration Rule) 22a-133k-2(c)(4)(C) Additional Polluting Substances - Pollutant Mobility Criteria 22a-133k-2(c)(6) Alternative Pollutant Mobility Criteria 22a-133k-2(d)(1) & (3) or (5) Alternative Pollutant Mobility Dilution/Dilution Attenuation Factor 22a-133k-2(d)(1) & (4) or (6) Alternative Analytical Method Pollutant Mobility Criteria 22a-133k-2(e)(2) Matrix Interference 22a-133k-2(e)(3)(A) and (C) Widespread Polluted Fill Variance 22a-133k-2(f)(1) Reuse of Polluted Soil 22a-133k-2(h)(3) Use of Engineered Control (EC) 22a-133k-2(f)(2)(B) GROUNDWATER REMEDIATION STANDARDS Alternative Method of Determining Compliance - Groundwater Criteria 22a-133k-3(g)(2)(A)(iii) Additional Polluting Substances Groundwater Protection Criteria 22a-133k-3(h)(1) Alternative Surface Water Protection Criteria 22a-133k-3(b)(3)(B) Alternative Volatilization Criteria 22a-133k-3(c)(4)(B) Exemption from Volatilization Criteria by Demonstrating no Building can be Constructed 22a-133k-3(c)(5)(A)

5 Indoor Air Monitoring Plan 22a-133k-3(c)(5)(B)(i) Matrix Interference 22a-133k-3(g)(3)(C) Variance Due to GW Technical Impracticability 22a-133k-3(e)(2) Environmental Land Use Restriction (ELUR) 22a-133q-1 DEP-REMED-PTP-ARN 2 of 3 Rev. Approval Request or Notice Form (continued) Rem#: Notices Submitted with this Transmittal Check each box that applies to the Notice (s) submitted with this Transmittal . Notices Required by the RSRs RSR Section References STANDARDS FOR SOIL REMEDIATION Intent to use existing structure to prevent human contact with polluted soil 22a-133k-1(a)(32)(D)(ii) Use of Background Concentration in Soil 22a-133k-2(a)(2) Soil VOC TCLP/SPLP Results to Comply with PMC in GA Areas 22a-133k-2(c)(2)(B)(ii)(cc) or (iii)(bb) Site-Specific Dilution in GB Area 22a-133k-2(c)(2)(E)(i)(bb) & (iii) Polluted Soil Reuse On-site 22a-133k-2(h)(3) Verify Public Notice of Use of Engineered Control 22a-133k-2(f)(2)(A)(iv)

6 Verify Financial Surety Mechanism in place* * Notice requested, not required GROUNDWATER REMEDIATION STANDARDS Measures to Prevent Migration of Vapor into Overlying Building 22a-133k-3(c)(3)(B)(iii) Certifications of Notifications of a GW Remediation Variance 22a-133k-3(e)(2)(C) Use of Upgradient Groundwater Policy * * Notice requested, not required Exemption for GW Background Due to Technical Impracticability * * Notice requested, not required Submit form and supporting documents to: Remediation Division, 2nd Floor, Bureau of Water Protection and Land Reuse Department of Energy and Environmental Protection 79 Elm Street, Hartford, Ct 06106 - 5127 DEP-REMED-PTP-ARN 3 of 3 Rev.

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