chk-200 environmental site assessment for limited remediation

Instructions for completing this checklist

• ALLrelevantSectionsofthischecklistmustbecompletedandmustaccompanytheEnvironmentalSiteAssessmentforLimitedRemediationReport.

• ThesignaturerequiredonthischecklistisfromthemanagingSiteProfessional.

• Allregulatoryprotocolsmustbefollowedandallforms/checklistsmustbecompletedseparatelyforeachproperty.Thismeansthatasourcepropertyandanimpactedthirdpartypropertymusthavealldocumentsfiledseparately.Oncethesourcepropertyorimpactedthirdpartypropertyisidentifiedbythecheckboxbelow,allsubsequentreferenceonthisform/checklistaretothatsiteowner.

• Forms/checklistsmustbecompletepriortofilingwiththeMinister.

1 - Site Location and Contact Information

Detailsprovidedonthisformareapplicableto q SourceProperty OR q ImpactedThirdPartyProperty

Site Location

Mandatorymustbecompleted.

SiteAddress____________________________________________________ City___________________

ParcelIdentificationNumber(PID) ___________________________________ PostalCode_____________

Additionalinformation,LotNo.,GPS,locationrelativetolandmark,etc._____________________________________________________________

Property Owner

Mandatorymustbecompleted.

Name _________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName(ifapplicable)_______________________________________ City___________________

MailingAddress__________________________________________________ PostalCode_____________

Recognized Agent

ThissectionisOptional.

Name__________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName__________________________________________________ City___________________


Contact for correspondence if different than above.

ThissectionisOptional.

Name__________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName(ifapplicable)_______________________________________ City___________________


Site Professional

Contact Information Name _________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName__________________________________________________ City___________________


2 - Environmental Site Assessment (ESA) Requirements for Limited Remediation

Type of Environmental Site Assessment conducted under Limited Remediation(Check type of ESA completed and complete corresponding section below)

q L1ESA q L2ESA q L3ESA

Environmental Site Assessment for Limited Remediation Checklist

ForallsitesundergoingL1,L2orL3LimitedRemediation

Environment

Document No.: CHK-200 of 5 Revision January 5, 2015

NSEFile#:

L1 Environmental Site Assessment Requirements SupportingInformation

provided

Reference Document

Confirm ALL of the following information has been submitted to the Department. Indicate Report and Page Number where information is documented. The Site Professional must ensure all work has been completed in accordance with the PRO-200, Environmental Site Assessment for Limited Remediation Protocol.

Yes Section PageNumber

Restrictions for use of L1Allavailablerecordsrelatedtoknownorpossiblecontaminationoftheproperty,mustbeobtained,reviewedandreported,fromthefirstknowndevelopedusetotheconclusionofthePhase1ESA,includingthefollowing

1 Contaminationhasnotextendedbelowthewatertable.Allpotentialpathwaysinthesubsurfacehavebeenfullyinvestigatedtoensurecontaminationhasnotcomeintocontactwithgroundwater

q

2 ContaminantslistedinSection4.1b)ofthePRO-200,Environmental Site Assessment for Limited Remediation ProtocolexceedingTier1EQScriteriaundergoingremediationwerenotpresentatadepthgreaterthan0.3mfromsurface

q

3 Contaminationhasnotdirectlyimpactedawatercourse,wetlandorpotablewatersupply q

4 Contaminationhasnotcomeincontactwithbedrockonapotablesite q

5 Measuresgreaterthanshort-termemergencyactionand/ortemporaryexcavationarenotrequiredtoaddressvapourswithinabuilding

q

Intrusive Investigation

6 AllcontaminationhasbeendelineatedtoappropriateTier1EQScriteriaspecifiedinthePro-100,Notification of Contamination Protocol

q

7 WiththeexceptionoftheevaluationprocessforinaccessiblesoilsbelowbuildingstructuresoutlinedinthisPRO-200,Environmental Site Assessment for Limited Remediation Protocol,includingtheuseofTier2PSStableswhereapplicable,allcontaminationhasbeenremediatedtoappropriateTier1EQScriteria

q

8 Airsamplingrequirementsnotapplicabletothesite;

or

whereapplicablesoilvapour,sub-slabandindoorairsamplingworkfollowedthelatestversionoftheAtlanticRBCAGuidanceforSoilVapourandIndoorAirMonitoringAssessmentsavailablefromtheAtlanticRBCAwebsite(atlanticrbca.com)

q

q

9 ConfirmatorysoilsampleshavebeencollectedfromthesidewallsandflooroftheexcavationinaccordancewithTable1(ConfirmatorySamplingRequirements)ofthePRO-700,Confirmation of Remediation Protocol

q

10 Contaminationdoesnotremainbelowanypartofabuildingfootprint;

or

wherecontaminatedsoilbelowanypartofabuildingfootprinthasbeenleftinplace,fulldelineationofcontaminationandverificationthroughsoilvapour,sub-slaborindoorairsamplingthattheindoorairqualityisnotaffectedaboveanacceptablelevelhasbeencompleted

q

q

11 Contaminationhasnotextendedtobedrock;

or

wherecontaminatedsoilhasextendedtobedrockonnon-potablesitesandnoevidenceoffreeproductispresent,thesiteprofessionalhasusedtheirprofessionaljudgementtodeterminewhetheragroundwaterassessmentisrequired.Incaseswhereitisdeterminedthatagroundwaterassessmentisnotrequired,andcontaminatedsoilcontainedgasolineorvolatileorganiccompoundsanevaluationofsoilvapour,sub-slaborindoorairhasbeenaccomplishedthroughthecollectionandinterpretationofempiricalsitedata

q

q

12 Compositesoilsamplingproceduresforvolatileorganiccompoundshavenotbeenused q

13 SItedoesnotrelyonapotablewellorspringsupplywatersource;

or

onsiteswherethereisapotablewellorspringsuppliedwatersource,thewellorspringhasbeenanalyzedforthecontaminantbeingaddressedinthesoil

q

q

14 AllsamplingandanalysishaveconformedtothelaboratoryrequirementsidentifiedinSection4.2.4ofthePRO-200,Environmental Site Assessment for Limited Remediation Protocol

q


Environmental Site Assessment for Limited Remediation ChecklistEnvironment


provided

Reference Document

Confirm ALL of the following information has been submitted to the Department. Indicate Report and Page Number where information is documented. The Site Professional must ensure all work has been completed in accordance with the PRO-200, Environmental Site Assessment for Limited Remediation Protocol.


ReportingTheenvironmentalsiteassessment,remedialactionplanandconfirmationreportrequirementsoftheContaminated Sites RegulationsmaybecompiledanddocumentedinasinglereportforanL1limitedremediation.ThetimerequirementsspecifiedintheContaminated Sites Regulationsmustbefollowed.

15 Acoverpagetitlethatidentifiesthesitelocation,siteowner(s)andsitename,ifapplicable q

16 Projectbackgrounddescription q

17 Basicsiteinformation,includingphysicaladdress,PIDandGPScoordinatesifavailable q

18 SummaryoftheresultsandfindingsoftheL1ESA q

19 Siteplan(s)showingthesitelocation,locationofsamplepoints.Allspatialinformationrepresentedonascaleddiagram

q

20 Resultsofallanalysesconducteddisplayedinatableandcomparedtorelevantenvironmentalqualitystandards,withexceedancevalues/datahighlighted

q

21 Interpretationandevaluationofthefindingsfromthesiteinvestigation,whichidentifyanddescribeanycontaminantsfoundatthesiteincludingconcentrations,locations,possiblesources,potentialpathwaysandreceptorsofconcern

q

22 ClearandconciseconclusionsoftheL1ESA,includingasummaryofrisksposedbycontaminantsremainingonsiteandpotentialrisktoreceptor(s)bothonandofftheproperty

q

23 Recommendationsregardingrisksposedbyanycontaminantsremainingonsite,andrecommendedaction(s)

q

24 Excavationpractices q

25 Soilsamplingproceduresusedforeachcontaminant q

26 QA/QCprocedures q

27 Copiesoflaboratoryanalyticaldatasheets q

28 Siteprofessionalsign-off,withoriginalorelectronicsignatures,andastamp/sealconfirmingthefindingsandconclusionscontainedinthereport

q


provided

Reference Document

Confirm the following information has been submitted to the Department. Indicate Report and Page Number where information is documented. The Site Professional must ensure all work has been completed in accordance with the PRO-200, Environmental Site Assessment for Limited Remediation Protocol.


Intrusive Investigation

1 Soilsamplingconductedatsourcearea(s) q

2 Groundwaterflowdirection,velocity,hydraulicgradient,andelevationhasbeenevaluatedbytheplacementofatleast3drilledboreholesandtheinstallationofmonitoringwellswithintheboreholes

q

3 Determinationhasbeenmadewhetherfreeproductinsoilorgroundwaterexistatthesite q

4 Horizontalextentofsoilcontaminationonandofftheproperty,foreachcontaminanthasbeendeterminedanddescribedintextandonagraphicalsiteplan

q

5 Theestimatedareaofsoilcontaminationexceedingapplicableenvironmentalqualitystandardsonandoffthepropertyhavebeencalculatedforeachcontaminant

q

6 Theverticalextentofsoilcontaminationonandoffthepropertyhasbeendetermined,includingthemaximumdepthatwhichcontaminationwasidentified,andconfirmationthattheverticaldepthofcontaminationhasbeendetermined,usingsiteprofilesasappropriate

q




provided

Reference Document



7 Thehorizontalandverticalextentofgroundwatercontamination,exceedingapplicableenvironmentalqualitystandardshasbeendetermined,onandoffthepropertyforeachcontaminant,andisdescribedintextandonagraphicalsiteplan

q

8 Sedimentandsurfacewaterhavenotbeenimpacted;

or

whereSedimentorsurfacewatercontamination,exceedingapplicableenvironmentalqualitystandardshasbeendetermined,contaminationisdescribedonagraphicalsiteplan

q

q

9 Adescriptionofregionaldrainage,geologyandhydrogeologyhasbeenprovided q

10 Adescriptionoflocaldrainage,geology,hydrogeology,andwateruse(obtainedthroughnonintrusivesiteinspection,intrusivesiteinvestigationandavailablesiteinformation)hasbeenprovided

q

11 LaboratoriesthathaveperformedanalysisareaccreditedtoISO/IEC17025standards(andsubsequentrevisions)bytheStandardsCouncilofCanada(SCC)ortheCanadianAssociationofLaboratoryAccreditationInc.(CALA)

q

12 Allsamplingandanalysishasbeenconductedinaccordancewithlaboratory-approvedrecommendationsconcerningsamplecontainers,storageandpreservation

q

13 Appropriatelaboratoryanalyticalmethodshavebeenusedtoensureadequateconformancetodataqualityobjectives,assessmentendpoints(ecologicalorhumanhealth)andmethod/reportabledetectionlimits

q

Reporting

14 AcoverpagetitlethatidentifiesaL2ESA,thesitelocation,siteowner(s)andsitename,ifapplicable

q

15 Projectbackgrounddescription q

16 Basicsiteinformation,includingphysicaladdress,PIDandGPScoordinatesifavailable q

17 SummaryofallpreliminaryworkandfieldactivitiesconductedatthesiteaspartoftheLimitedPhase2ESAprogram

q

18 Conceptualsitemodelwhichrepresentanunderstandingofthesitecharacteristics,includingexpectedlocationsofcontaminants,likelycontaminanttransportmechanisms,andtheexistenceofpotentiallypreferentialpathwaysforcontaminanttransporttoreceptors

q

19 Adescriptionofgeological,hydrogeologicalandhydrologicalinformationasrequiredbythisPRO-200,Environmental Site Assessment for Limited Remediation Protocol

q

20 Siteplansshowingthesitelocation,locationofsamplepoints,groundwaterelevationmaps,andlocation(s)ofsamplesexceedingtheapplicableregulatorycriteria.Locationswherecontaminantconcentrationsexceedbackgroundvaluesshouldalsobeidentified.Allspatialinformationmustberepresentedonascaleddiagram

q

21 Resultsofallanalysesconductedaredisplayedinatableandcomparedtorelevantenvironmentalqualitystandards,withexceedancevalues/datahighlighted

q

22 Interpretationandevaluationofthefindingsfromthesiteinvestigation,whichidentifyanddescribeanycontaminantsfoundatthesiteincludingconcentrations,locations,source,potentialpathwaysandreceptorsofconcern

q

23 ClearandconciseconclusionsoftheLimitedPhase2ESA,includingasummaryofrisksposedbycontaminantsremainingonsiteandpotentialrisktoreceptor(s)bothonandofftheproperty

q

24 Recommendationsregardingrisksposedbyanycontaminantsremainingonsite,andrecommendedaction(s)

q

25 AlistofanyreferencesandsupportingdocumentationusedinthepreparationoftheLimitedPhase2ESAreport

q

26 Completetestpit,boreholestratigraphic,andmonitoringwellinstallationlogs q

27 Boreholedrillingpractices q




provided

Reference Document



28 Excavationpractices qN/A q

29 Soilsamplingproceduresusedforeachcontaminant q

30 Monitoringwellinstallation,developmentandgroundwatersamplingprocedures q

31 QA/QCprocedures q

32 Copiesoflaboratoryanalyticaldatasheets q

33 Siteprofessionalsign-off,withoriginalorelectronicsignatures,andastamp/sealconfirmingthefindingsandconclusionscontainedinthereport

q


provided

Reference Document

Confirm the following information has been submitted to the Department. Indicate Report and Page Number where information is documented. The Site Professional must ensure all work has been completed in accordance with the Environmental Site Assessment for Limited Remediation Protocol.


Investigation

1 Phase1ESAconductedinaccordancewithPRO-300,Phase 1 ESA Protocol q

2 Phase2ESAconductedinaccordancewithPRO-400,Phase 2 ESA Protocol q

Reporting

3 Phase1ESAreportingrequirementscompletedinaccordancewithPRO-300,Phase 1 ESA Protocol

q

4 CHK-300,Phase1ESAchecklisthasbeencompletedandappendedtothischecklist q

5 Phase2ESAreportingrequirementsconductedinaccordancewithPRO-400,Phase 2 ESA Protocol

q

6 CHK-400,Phase2ESAchecklisthasbeencompletedandappendedtothischecklist q

3 - Declaration

Site Professional Declaration

IacknowledgeitisanoffenceunderSection158oftheEnvironment Acttoprovidefalseormisleadinginformation,andconfirmtothebestofmyknowledgeandbelieftheinformationprovidedinthisformandsupportingdocumentationistrueandaccurateandcomplieswiththerelevantprovisionsoftheEnvironment ActandContaminated Sites Regulations.Bysigningbelow,Iconfirmmyqualificationsandliabilityinsuranceasasiteprofessionalasprescribedwithintheregulations.

q Reportsandchecklist/shavebeenprovidedtoaffectedpropertyowner.

Name(Print)__________________________________________ ProfessionalRegistrationNumber/Stamp_________________

Signature __________________________________________ Date _______________________ SiteProfessional MM/DD/YYYY

Return completed form and associated documents to the Department of Environment Regional Office.TofindyourRegionalOfficegoonlineatnovascotia.ca/nse/dept/division.emc.asp#centralorcall1-877-936-8476



chk-200 environmental site assessment for limited remediation

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