Fillable Form 4400-248 (R 12/09) Page 1 of 5: (Wisconsin)

Fill Online, Printable, Fillable, Blank Form 4400-248 (R 12/09) Page 1 of 5: (Wisconsin) Form

Use Fill to complete blank online WISCONSIN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 4400-248 (R 12/09) Page 1 of 5: (Wisconsin)

On average this form takes 27 minutes to complete

The Form 4400-248 (R 12/09) Page 1 of 5: (Wisconsin) form is 4 pages long and contains:

  • 0 signatures
  • 31 check-boxes
  • 95 other fields

Country of origin: US
File type: PDF

BROWSE WISCONSIN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Accumulated Sediment End Use Certification
Form 4400-248 (R 12/09) Page 1 of 5
State of Wisconsin
Department of Natural Resources
PO Box 7921, Madison WI 53707-7921
dnr.wi.gov
Notice: This form must be completed and retained by the sediment manager prior to the initiation of the end use of accumulated
sediment from a stormwater management structure, in accordance with ch. NR 528, Wis. Adm. Code. Completion of the worksheets
included in this form directs the user to the appropriate level of certification necessary to comply with the requirements of ch. NR 528.
Failure to accurately fill out this form or comply with the requirements of ch. NR 528 is subject to enforcement under ss. 289.96 and
299.97, Wis. Stats. The user may consult technical support materials provided by the department to assist in the management of
accumulated sediment in a beneficial and safe manner. Personal information is not intended to be used for any other purpose, but may
be made available to requesters under Wisconsin's Open Records laws (s. 19.35, Wis. Stats.).
NOTE: See last page of form for definitions and other information that may help complete this form.
Instructions: Anyone completing this form must complete Sections 1, 2 and 3. Unless otherwise directed, the sediment manager shall
complete Part A, and if appropriate, ensure that Part B is completed. Complete Part C if the sediment will be used in a dedicated
sediment management site and Part D if 100 cubic yards or less of coarse-grained sediment will be used. Please refer to WA1375
Management of Accumulated Sediment from Storm Water Structures at http://dnr.wi.gov/org/aw/wm/publications/anewpub/wa1375.pdf
when completing this form.
Section 1: Sediment Manager Information
Sediment Manager's Name Affiliation
Title Telephone Number
Address City State ZIP Code
Email Address
Section 2: Site-specific Information
Name of Storm Water Management Structure Site/Property Identification No. (if known)
Address City State ZIP Code
County Township
N
Range
E
W
Section
¼
¼ ¼
Latitude (decimal degrees)
Longitude (decimal degrees)
Construction Year Volume Removed (in cubic yards)
Date Sediment Was Last Removed (if applicable)
Section 3: End Use Site Information
Name of End Use Site Site/Property Identification No. (if known)
Address City State ZIP Code
County Township
N
Range
E
W
Section
¼
¼ ¼
Latitude (decimal degrees)
Longitude (decimal degrees)
General Fill
Confined Geotechnical Fill
Landspreading
Dedicated sediment management site
Briefly describe end use (e.g., subbase layer beneath parking lot)
List the type of use chosen for the accumulated sediment (check all that apply):
Small Quantity, Coarse Gained Sediment Mgnt
End use under other control
Clear Data
Print...
Save...
Accumulated Sediment End Use Certification
Form 4400-248 (R 12/09) Page 2 of 5
Part A Sediment Manager Certification
To be completed by the sediment manager to evaluate the drainage area from which the accumulated sediment was removed and
determine if the certification criteria listed below have been met.
Part A Worksheet
Information on Drainage Area to Storm Water Management Structure
Percent of Land Uses
Open space (parks, cemeteries, woodlands, golf courses)
1- and 2-family residential
Multi-family residential (3 or more)
Institutional (schools, hospitals, churches, offices)
Light industrial (no outdoor material storage)
Commercial (malls, shopping centers)
Heavy industrial (some outdoor material storage)
Presence of Areas of Suspected
Contamination or Other Concerns
Based on Site History (Yes or No)
Outside storage and loading areas of industries
NoYes
Vehicle fueling and maintenance areas (gas stations)
NoYes
Arterial roads (multi-lane, high traffic)
NoYes
Commercial with 40 or more stalls
NoYes
Leaking underground storage tanks currently or previously on property
NoYes
Spills of chemicals, oil or hazardous materials
NoYes
Dedicated snow storage areas
NoYes
Agriculture land use history suggests persistent pesticides may be in sediment
NoYes
Other?
NoYes
Refer to Part A Worksheet prior to certifying the information below. Based on Part A Worksheet and pursuant to
s. NR 528.06(2) Wis. Adm. Code, I determine the drainage area to the storm water management structure meets
the following criteria (check any that apply):
1. Has less than 15% commercial, multi-family residential, institutional and industrial land uses combined.
2. Has no areas of suspected contamination.
3. Has no other existing conditions or known historical events that may affect the likelihood of safe sediment management.
4. Has no reported hazardous substance spills per s. 292.11, Wis. Stats. since construction or since accumulated sediment was
last removed (provide date of last sediment removal in Section 2).
Based on whether the above four criteria are met, the following steps have been taken (check any which apply):
The drainage area to the storm water management structure meets all 4 criteria listed above and in s. NR 528.06(2), Wis. Adm.
Code so sampling under s. NR 528.06(3), Wis. Adm. Code is not required and I am certifying under Part A and do not have to
complete Part B.
The drainage area to the storm water management structure does not meet all four criteria so sampling under s. NR 528.06(3), Wis.
Adm. Code is required and an environmental professional must certify under Part B.
Records are being maintained as follows (check if true):
Record retention is being performed in accordance with s. NR 528.08, Wis. Adm. Code.
Certification Statement
I hereby certify that the accumulated sediment will be used in the manner specified in Section 3, the performance standards in
s. NR 528.04(2), Wis. Adm. Code and locational criteria, if applicable, in s. NR 528.04(1), Wis. Adm. Code will be met, and the erosion
control measures in s. NR 528.04(3), Wis. Adm. Code will be implemented. I certify that the information provided in sections 1, 2 and 3
and Part A on this form is true, accurate and complete to the best of my knowledge and I agree to retain this form and other data
records in accordance with s. NR 528.08, Wis. Adm. Code. I am aware that violation of these requirements is subject to enforcement
under ss. 289.96 and 299.97 Wis. Stats.
Sediment Manager Title Date Signed
Accumulated Sediment End Use Certification
Form 4400-248 (R 12/09) Page 3 of 5
Part B Professional Certification: Must be completed by a professional geologist, hydrologist, engineer or soil scientist
Based on information obtained in Part A, the following action was taken (check those that apply):
The drainage area meets criteria 2, 3 and 4 but does not meet criterion 1, so initial sampling under NR 528.06(3)(b)1. to 4. was
performed under my direction. I reviewed the results and have determined the following actions will be taken (check any which apply):
The drainage area does not meet criteria 2, 3 or 4, so go to Part B1 to determine additional parameters to add to the initial sampling.
NR 528.04(4) Table 2 ceiling levels were exceeded so the sediment will be taken to a licensed landfill.
NR 528.04(4) Table 2 ceiling levels were not exceeded but sampling results for indicator parameters listed under NR 528.06(3)
(b)3 and 4 indicated elevated levels of contaminants, so follow-up sampling in accordance with NR 528.06(3)(b)5 has been
performed and I have evaluated the results under Part B2.
NR 528.04(4) Table 2 ceiling levels were not exceeded and the sampling results for indicator parameters listed under NR 528.06
(3)(b)3 and 4 did not indicate elevated levels of contaminants, so I am recommending the end use described under Section 3
and complete certification statement.
Part B1 Worksheet: Information on Drainage Area to Storm Water Management Structure
Part B1: Only to be completed if criteria 2, 3 or 4 in Part A are not met.
Presence of Areas of Suspected Contamination
or Other Conditions or Events (Example)
Provide Details
Tier I Industry (NR 216.21(2)(a))
Tier II storage and loading areas
(NR 216.21(2)(b))
Brownfields
Oil or chemical spill has occurred
Agriculture land use history suggests persistent
pesticides may be in sediment.
Other uses such as but not limited to those in
Part A Worksheet
I completed Part B1 Worksheet and determined an appropriate management option (check if true):
Based on the results of the second half of Part A Worksheet and Part B1 Worksheet, I have added the appropriate additional
parameters to the initial sampling under NR 528.06(3)(b)1 to 4, performed initial sampling, saw no elevated levels of contaminants
and am recommending the end use listed in Section 3.
The initial sampling performed after adding additional parameters indicated elevated levels of contaminants so I will follow the steps
in Part B2 to determine an appropriate end use.
Part B2: To be completed if directed here from Part B1 or if ceiling levels were not exceeded but initial sampling results
under NR 528.06(3)(b)1 to 4 indicated elevated levels of contaminants.
Initial sampling results under NR 528.06(3)(b)1 to 4 indicated elevated levels of contaminants so the following
action occurred (check those that apply):
Follow-up sampling was performed in accordance with NR 528.06(3)(b)5 and the results evaluated.
The end use listed under Section 3 was chosen.
The end use listed under Section 3 was chosen and more stringent management was employed under my direction.
Record retention is being performed in accordance with NR 528.08.
Certification Statement
I am a professional engineer registered to practice in Wisconsin or a geologist, hydrologist or soil scientist licensed to practice in
Wisconsin and am qualified by training and experience to evaluate the potential for soil, surface water and groundwater contamination
from the end use of accumulated sediment.
I hereby certify that the accumulated sediment is not a hazardous waste, as defined by s. NR 661.03, Wis. Adm. Code. I hereby certify
that the information provided in Part B, B1 and B2 on this form is true, accurate and complete to the best of my knowledge. Based on
my evaluation of the accumulated sediment sampling results, intended end use, site-specific factors at the end use site and
management practices I certify that if the end use chosen in Section 3 is properly implemented, the site will meet the applicable
requirements of s. NR 528.04, Wis. Adm. Code and it is likely the site will not cause any significant risk to public health, safety or
welfare or the environment. My professional opinion is given to a reasonable degree of professional certainty, and is based upon my
evaluation of reasonable and sufficient information and generally accepted engineering and scientific practices. I am aware that
violation of these requirements is subject to enforcement under secs. 289.96 and 299.97 Wis. Stats.
Engineer/Geologist/Hydrologist/Soil Scientist Title Registration No. Date Signed
Accumulated Sediment End Use Certification
Form 4400-248 (R 12/09) Page 4 of 5
Part C Dedicated Sediment Management Site Certification
To be completed by the sediment manager wishing to use accumulated sediment at a dedicated sediment management site in
accordance with NR 528.07(5). Sections 1, 2 and 3 at the beginning of the form must also be completed.
The following management requirements have been implemented at the dedicated sediment management site
(check those that apply):
Site is owned or leased by a municipality or other responsible unit of government.
Sediment application at a depth of 18 inches or less below ground surface.
Additional practices to control run-on and runoff or monitoring of soils, plant tissue or other environmental receptors or evaluation of
sampling data to ensure safe long term site use pursuant to NR 528.07(4)(b).
Record retention is being performed in accordance with NR 528.07(5)(d).
An affidavit indicating the site has been used as a dedicated sediment management site has been filed in the registrar of deeds
office in the county where the site is located.
Certification Statement
I am a professional engineer registered to practice in Wisconsin or a geologist, hydrologist or soil scientist licensed to practice in
Wisconsin and am qualified by training and experience to evaluate the potential for soil, surface water and groundwater contamination
from the end use of accumulated sediment.
I hereby certify that the accumulated sediment is not a hazardous waste, as defined by s. NR 661.03, Wis. Adm. Code. I hereby certify
that the information provided in Part B, B1 and B2 on this form is true, accurate and complete to the best of my knowledge. Based on
my evaluation of the accumulated sediment sampling results, intended end use, site-specific factors at the use site and management
practices I certify that if the end use chosen in Section 3 is properly implemented, the site will meet the applicable requirements of s.
NR 528.04, Wis. Adm. Code and it is likely the site will not cause any significant risk to public health, safety or welfare or the
environment. My professional opinion is given to a reasonable degree of professional certainty, and is based upon my evaluation of
reasonable and sufficient information and generally accepted engineering and scientific practices. I am aware that violation of these
requirements is subject to enforcement under secs. 289.96 and 299.97 Wis. Stats.
Engineer/Geologist/Hydrologist/Soil Scientist Title Registration No. Date Signed
Part D Coarse Grained Sediment Certification
To be completed by the sediment manager wishing to dispose of 100 cubic yards or less of primarily coarse grained accumulated
sediment such as that found in the forebay. Sections 1, 2 and 3 at the beginning of the form must also be completed.
The following criteria are met (check those that apply):
1. The quantity of accumulated sediment to be managed is 100 cubic yards or less.
2. No more than 15% of the accumulated sediment material, percent by weight, passes a No. 200 sieve.
3. As sediment manager I agree to maintain responsibility for disposal of the accumulated sediment.
All three criteria listed in Part D are met, so the material does not need to be sampled and the sediment shall be managed in
accordance with NR 528.04(1) and (2).
One or more of the three criteria listed in Part D are not met, so the material may not be managed under NR 528.07(6) so it must be
managed under NR 528.05.
Record retention is being performed in accordance with NR 528.08.
Certification Statement
I hereby certify that the accumulated sediment will be used in the manner specified in Section 3 and in accordance with ch. NR 528,
Wis. Adm. Code and, the performance standards in s. NR 528.04(2), Wis. Adm. Code will be met. The information provided in sections
1, 2 and 3 and Part D is true, accurate and complete to the best of my knowledge. This form and other data records will be retained in
accordance with s. NR 528.08, Wis. Adm. Code. I am aware that violation of these requirements is subject to enforcement under
secs. 289.96 and 299.97 Wis. Stats.
Sediment Manager Title Date Signed
Save...
Accumulated Sediment End Use Certification
Form 4400-248 (R 12/09) Page 5 of 5
Information To Help Complete The Certification Form
NR 528.03 Definitions
“Sediment manager” means any person with responsibility for the management of the accumulated sediment and may
include those holding fee title, an easement or other interest in a property, or their agent, including contractors or
subcontractors and others required or authorized to undertake removal and subsequent management of accumulated
sediment, including data gathering, reporting and recordkeeping.
“Environmental professional” means a professional engineer registered pursuant to s. 443.04, Wis. Stats. or a
professional soil scientist, geologist or hydrologist licensed under ch. 470, Wis. Stats.
NR 528.04(2) Performance standards.
(a) No person may use or dispose of accumulated sediment at a site if there is a reasonable probability that the sediment
end use will cause any of the following:
1. A significant adverse impact on wetlands as defined in ch. NR 103.
2. A take of an endangered or threatened species prohibited by s. 29.604, Stats.
3. A detrimental effect on any surface water.
4. A detrimental effect on groundwater quality that will cause or exacerbate an exceedance of any preventive action limit
or enforcement standard at a point of standards application as defined in ch. NR 140. The point of standards application
is defined by s. NR 140.22 (1).
NR 528.04(3) Erosion control measures.
The sediment manager shall ensure that measures are taken to control run-on and runoff, minimize the area disturbed by
the project, minimize loss of fugitive dust and retain sediment on the site during and after the placement of the
accumulated sediment. Runoff control measures shall be effectively inspected and maintained. Any area where topsoil is
exposed shall be seeded and mulched or otherwise stabilized within 48 hours of placement. Where applicable, the
requirements in ch. NR 216 shall be followed.
Separation
Distance in Feet
Bedrock
or
Groundwater
Table
3
Public
Water
Supply
Well
1,200
Private
Water
Supply
Well
250
Lake, Wetland,
Pond, or Any
Navigable Waterway
or Sinkhole
200
Residence
250
School,
Healthcare
Facility
1,000
1
surface spread
500
incorporated
1
The 1,000 foot separation applies when the pathogen or indicator organism level exceeds the criteria specified in s. NR 204.07(6) and application to
the surface of the land is the desired management option; if incorporated into the soil, then 500 feet is appropriate. However, if the pathogen or indicator
organism level is below the criteria, the setback distance for a residence may be used.
Table 1
Locational Criteria for Management of Accumulated Sediment
Table 2
Ceiling Levels Governing Management of Accumulated Sediment
Total Arsenic
Parameter
Ceiling Level ppm or mg/kg on a dry weight basis
unless otherwise specified
8
Total Cadmium
10
100
Total Chromium
250
Total Lead
pH Less than 5 or greater than 10 standard units
8 deciSiemens/meter (dS/m)
1
at 25
o
C
Electrical conductivity
1
deciSiemens/meter (dS/m) and mmhos per centimeter are equivalent; dS/m is the modern nomenclature.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 4400-248 (R 1209) Page 1 of 5: (Wisconsin)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document