Fillable Massachusetts Department of Environmental Protection - BWSC123 Notice of Environmental Sampling

Fill Online, Printable, Fillable, Blank Massachusetts Department of Environmental Protection - BWSC123 Notice of Environmental Sampling Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Massachusetts Department of Environmental Protection - BWSC123 Notice of Environmental Sampling

On average this form takes 8 minutes to complete

The Massachusetts Department of Environmental Protection - BWSC123 Notice of Environmental Sampling form is 2 pages long and contains:

  • 0 signatures
  • 18 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) 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
 
NOTICE OF ENVIRONMENTAL SAMPLING
Bureau of Waste Site Cleanup
As required by 310 CMR 40.1403(10) of the Massachusetts Contingency Plan
This Notice is Related to:
Telephone: __________________________ Email: _____________________________
Release Tracking Number
City/Town: ________________________ Zip Code: ___________
Street Address: ___________________________________________________
Contact Name: ____________________________________________
1. Street Address: ___________________________________________________
E. Contact information related to the party providing this notice:
City/Town: _________________________ Zip Code: ____________
4. Description of the sampling locations and types (e.g., soil, groundwater, indoor air, soil gas) to the extent known at the
time of this notice.
B. This notice is being provided to the following party:
(specify)
1. Name: __________________________________________
-
residential commercial industrial school/playground Other___________________
2. Street Address: ___________________________________________________
3. Description of property where sampling will be/has been conducted:
City/Town: _________________________ Zip Code: ___________
(specify)
C. This notice is being given to inform its recipient (the party listed in Section B):
Phase II Comprehensive Site Assessment Other _________________________
1. That environmental sampling will be/has been conducted at property owned by the recipient of this notice.
Phase I Initial Site Investigation Post-Temporary Solution Operation, Maintenance and Monitoring
2. Of the results of environmental sampling conducted at property owned by the recipient of this notice.
Utility-related Abatement Measure Phase V/Remedy Operation Status
the environmental sampling must be attached to this notice.)
Release Abatement Measure Phase IV Remedy Implementation Plan
Immediate Response Action Phase III Feasibility Evaluation
D. Location of the property where the environmental sampling will be/has been conducted:
2. MCP phase of work during which the sampling will be/has been conducted:
1. Street Address: ___________________________________________________
City/Town: _________________________ Zip Code: ___________
3. Check to indicate if the analytical results are attached. (If item 2. above is checked, the analytical results from
BWSC123
Massachusetts Department of Environmental Protection
Revised: 5/30/2014
Page 1 of 2
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 E on the reverse side 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.
MASSACHUSETTS REGULATIONS THAT REQUIRE THIS NOTICE
FOR MORE INFORMATION
This notice is being provided pursuant to the Massachusetts Contingency Plan and the notification
requirement at 310 CMR 40.1403(10). 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.
Section D on the reverse side of this form identifies the property where the environmental
sampling will be/has been conducted, provides a description of the sampling locations within the
property, and indicates the phase of work under the Massachusetts Contingency Plan regulatory
process during which the samples will be/were collected.
Section C on the reverse side of this form indicates the circumstance under which you are
receiving this notice at this time. If you are receiving this notice to inform you of the analytical
results following the analysis of the environmental samples, you should also have received, as an
attachment, a copy of analytical results. These results should indicate the number and type(s)
of samples (e.g., soil, groundwater) analyzed, any chemicals identified, and the measured
concentrations of those chemicals.
THE PERSON(S) PROVIDING THIS NOTICE
When environmental samples are taken as part of an investigation of a release for which a
notification to MassDEP has been made under the Massachusetts Contingency Plan (310 CMR
40.0300) on behalf of someone other than the owner of the property, the regulations require
that the property owner (listed in Section B on the reverse side of this form) be given notice of
the environmental sampling. The regulations also require that the property owner subsequently
receive the analytical results following the analysis of the environmental samples.
PURPOSE OF THIS NOTICE
This notice has been sent to you by the party who is 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
regulations refer to the area where the oil or hazardous material is present as the “disposal site”.)
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup
NOTICE OF ENVIRONMENTAL SAMPLING
As required by 310 CMR 40.1403(10) of the Massachusetts Contingency Plan
BWSC123
This Notice is Related to:
Release Tracking Number
-
Revised: 5/30/2014
Page 2 of 2
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

Massachusetts Department of Environmental Protection - BWSC123 Notice of Environmental Sampling

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 20 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document