Fillable Massachusetts Department of Environmental Protection - BWSC122 Informational Notice to Property Owners

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Massachusetts Department of Environmental Protection - BWSC122 Informational Notice to Property Owners

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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i. An Activity and Use Limitation has been implemented.
BWSC122
Bureau of Waste Site Cleanup
This notice is related to:
Release Tracking Number
INFORMATIONAL NOTICE TO PROPERTY OWNERS
-
As Required by 310 CMR 40.1406 of the Massachusetts Contingency Plan (MCP)
1. Street Address:
6. Soil Gas
2. City/Town:
B. THIS NOTICE IS BEING PROVIDED TO THE FOLLOWING PROPERTY OWNER:
3. ZIP Code:
3. Assessor's Parcel ID:
1. A Copy of the Map Showing or a Description Describing the Area where the Oil and/or Hazardous Material is or is
c. ZIP Code:
C. THIS NOTICE IS BEING GIVEN : (check one)
1. Upon Completion of a Phase II Comprehensive Site Assessment.
b. City/Town:
3. Upon Completion of Additional Investigation showing that Oil or Hazardous Material is not Present at the Property.
D. DESCRIPTION OF OIL AND/OR HAZARDOUS MATERIAL PRESENT OR LIKELY TO BE PRESENT AT THE PROPERTY :
(check all that apply)
AFFECTED ENVIRONMENTAL MEDIA
PRINCIPAL CHEMICAL(S) PRESENT
a. Street Address:
2. Address of Property For Which This Notice is Being Provided: (property owned by person named in B1)
1. Name of Property Owner:
1. Soil
E. ATTACHMENTS PROVIDED WITH THIS NOTICE, AS REQUIRED BY 310 CMR 40.1406:
2. Groundwater
likely to be Present.
3. Surface Water
4. Sediment
5. Indoor Air
7. Other:
(specify)
ii. An Activity and Use Limitation has not been implemented.
3. Temporary Solution.
2. Permanent Solution with Conditions.
1. Permanent Solution with No Conditions.
3. Specify the category of Solution that applies to the Disposal Site.
2. A Copy of the Phase II Comprehensive Site Assessment or Permanent or Temporary Solution Statement Conclusions.
2. Upon Submittal of a Permanent or Temporary Solution Statement (i.e., Site Closure Report).
Massachusetts Department of Environmental Protection
Page 1 of 2
Revised: 5/30/2014
4. Assessor's Parcel ID:
F. CONTACT INFORMATION RELATING TO THE PARTY PROVIDING THIS NOTICE:
1. Name of Organization:
2. Contact First Name:
3. Last Name:
4. Street:
Massachusetts Department of Environmental Protection
BWSC122
Bureau of Waste Site Cleanup
This notice is related to:
Release Tracking Number
INFORMATIONAL NOTICE TO PROPERTY OWNERS
-
As Required by 310 CMR 40.1406 of the Massachusetts Contingency Plan (MCP)
6. City/Town:
Page 2 of 2
Revised: 5/30/2014
PURPOSE OF THIS NOTICE
5. Title:
Parties who are taking actions to respond to releases of oil or hazardous material to the environment are required by
state regulations (referred to above) to notify the owners of property where the oil or hazardous material is or is likely
to be present. These same parties are also required to notify property owners upon completion of actions to address
the oil or hazardous material, or if additional investigations show that the oil or hazardous material is not present at a
property. Section C on the reverse side of this form indicates the circumstance under which you are receiving this
notice at this time.
INFORMATION RELATED TO YOUR PROPERTY
Section D on the reverse side of this form indicates the type(s) of oil or hazardous material that is or is likely to be
present at your property, and the environmental medium (e.g., soil or groundwater) where it is or is likely to be
present. Please note that when an investigation indicates that the oil or hazardous material is or is likely to be
present at your property, this does not mean that the oil or hazardous material is posing a health risk to you. Parties
who are taking actions to address oil and hazardous material releases are required by state regulations to adequately
investigate these releases and take necessary actions to ensure that affected properties meet standards that are
protective of human health and the environment.
ATTACHED MAP OR DESCRIPTION AND REPORT CONCLUSIONS
The party providing this notice to you is required to attach a map or description that indicates the boundaries of the
area where the oil or hazardous material is or is likely to be present, and the conclusions of the site investigation or
closure report (Section E). These attachments should give you additional information about the nature and location
of the oil or hazardous material with respect to your property.
This notice is being provided pursuant to the Massachusetts Contingency Plan and the notification
requirement at 310 CMR 40.1406. The Massachusetts Contingency Plan is a state regulation that specifies
requirements for parties who are taking actions to address releases of chemicals (oil or hazardous material)
to the environment.
MASSACHUSETTS REGULATIONS THAT REQUIRE THIS NOTICE
FOR MORE INFORMATION
Information about the general process for addressing releases of oil or hazardous material under the
Massachusetts Contingency Plan and related public involvement opportunities may be found at
http://www.mass.gov/eea/agencies/massdep/cleanup.
For more information regarding this notice, you may contact the party listed in Section F of this form. Information
about the disposal site identified in Section A is also available in files at the Massachusetts Department of
Environmental Protection.
See http://public.dep.state.ma.us/SearchableSites2/Search.aspx to view site-specific files on-line or
http://mass.gov/eea/agencies/massdep/about/contacts/conduct-a-file-review.html if you would like to make an
appointment to see these files in person. Please reference the Release Tracking Number listed in the upper right
hand corner on the reverse side of this form when making file review appointments.
8. ZIP Code:
This notice has been sent to you by the party(ies) who is/are addressing a release of oil or hazardous material to
the environment at the location listed in Section A on the reverse side of this form.
THE PERSON(S) PROVIDING THIS NOTICE
7. State:
10. Email:
9. Telephone:
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Massachusetts Department of Environmental Protection - BWSC122 Informational Notice to Property Owners

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Completed 18 May 2020

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