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Transcript
Contaminated Soil Permits UST-71 North Carolina Division of Waste Management UST-71 Certificate of Approval for Storage/Treatment of Soil Containing Petroleum Products Certificate #__________________ Of 50 Cubic Yards or Less Temporary Storage Other (explain below) Approval is Hereby Granted To: Name:____________________________________ Phone Number:_____________ Address: ____________________________________________________________ ____________________________________________________________ for the storage/treatment of approximately ________ cubic yards of contaminated soil as specified below: Type of Contaminants: ____________________________________________________________________________ Location of Source of Contaminant(s) (including business/owner name): ______________________________________ ________________________________________________________________________________________________ Address of Source of Contaminant: ___________________________________________________________________ _________________________________________________________________________________________________ County: ____________________________ Method of Storage/Treatment: _______________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Location(s) where contaminated soil will be stored or applied of (map(s) must be provided): ______________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ This approval is based upon information provided to the Regional Supervisor, __________________ Regional Office, by the responsible party, who hereby agrees to conduct the approved soil management activities in accordance with applicable state, local or federal requirements and additionally agrees to abide by any special conditions or limitations specified below and on the second page of this form. (NOTE: If the contaminated soil to be managed is regulated under Subtitles C or D of RCRA, then the soil shall not be stored or treated without written permission from the NC Division of Waste Management.) Special Conditions, Limitations or Comments: __________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Certificate of Approval issued this the __________ day of __________________, 20___. ______________________________________ ____________________________________ Signature of DWM Representative Signature of Responsible Party ___________________________ Regional Office UST-71 (07/03) September 1, 2003 Page 1 of 2 Contaminated Soil Permits UST-71 UST-71 Certificate of Approval for Storage/Treatment of Soil Containing Petroleum Products Special Conditions, Limitations or Comments (continued): Soil Quarantine requirements 15A NCAC 2H .0217(f) Land Use Agreement as described in 15A NCAC 2H .0205(d)(12)(a)(vii) Performance Standards 15A NCAC 2H .0217(f) Buffer Requirements (NCAC 15A 2H .0219(j)): a) 100 feet from any habitable residence or place of public assembly under separate ownership or which is to be sold; b)100 feet between the application area and any public or private water supply, including wells; c) 100 feet between application area and waters classified as WS-II, WS-III, or B; d)100 feet between the application area and the normal high water levels of waters classified as SA or SB; e) 100 feet between application area and any stream, lake, river or natural drainage way; f) 50 feet between application area and property lines; g)10 feet between application area and surface water interceptor drains or diversions (up slope); h)25 feet between application area and any surface water interceptor drains or diversions (down slope) and any groundwater drainage systems; and i) 10 feet of area shall be maintained around the application area with a permanent vegetative cover to be included within any of the existing buffers where applicable. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ UST-71 (07/03) September 1, 2003 Page 2 of 2