Landmark 6, Suite 700

1631 Dickson Avenue

Kelowna, BC

Canada V1Y 0B5

T: +1 250 980-5500

F: +1 250-980-5511

wsp.com

MEMO

TO: City of Kelowna, Jason Issler

FROM: WSP Canada Inc, Andrew Bruce

SUBJECT: Temporary Use Permit for Operation of a Crusher

DATE: January 27, 2021

INTRODUCTION

Please find the accompanying application forms, fees and title information for a Temporary Use

Permit for 2205 and 2125 Baron Road and 1880 Leckie Road. This is the site for the proposed

new Costco Warehouse. 1901 Baron Road is also part of the overall development site but the

Temporary Use Permit does not need to apply to this address.

The request for the temporary use permit is to permit the use of a mobile rock crusher on site for a

limited portion of the construction stage and within limited operating hours per day. The City of

Kelowna’s current position is that crushing plants are not permitted to operate outside of I5 –

Extraction zoned properties. The material that would be processed would consist of “oversized”

rock or cobble. This native material is too large to be used for any part of the site grading or

underground works. If it can be processed or crushed on site, it can be made into a range of

material from appropriate base material, granular fills and structural fill. If it cannot be processed

on site, it needs to be hauled off-site to a gravel pit.

Our proposal includes specific siting criteria to provide adequate distance separation from adjacent

residential, a specific number of days of operation (duration), and mitigation efforts for dust.

Finally, we provide some data on noise that compares the operation of the mobile crushing plant to

source of noise emission that are considered as acceptable normal construction activities. We will

also speak to the reasons why allowing the mobile crushing operation on site has broader benefits

to the community.

PROPOSED LOCATION

The attached Schedule A shows the proposed location parameters for the mobile crushing plant.

The larger green circle is the proposed minimum distance away from residential uses where the

crushing plant could be placed to operate. While these crusher are “mobile” they typically aren’t

moved more than once a day. It is more likely that they would be moved to a location and operate

for several days in one place. They are really only moved to get them out of the way of other site

work.

Page 2

The 20 m smaller circle is the actual extent of the operation zone around the crushing plant.

OPERATION PARAMETERS

WSP is providing Civil Engineering services to the Costco group, has reviewed the Geotechnical

Engineering reports and coordinated with civil contractor to estimate the amount of material that

could be processed for re-use on the site. There is not material that will be process and exported

from the overall Costco development site (Warehouse and Gas Bar sites). The estimated amount

of material is approximately4,500 cubic metres. This would equate to approximately 320 tandem

dump truck loads if the material could not be processed on site.

These quantity estimates have been used to calculate the amount of time required to process the

oversized material into usable granular material for site construction. It is proposed that crushing

operation be permitted to operate the same as any other equipment on site which is subject to the

City of Kelowna Noise Bylaw. In order to minimise crushing duration, material will be stockpiled

at or near the crushing plant to be processed in batches. This means that the crushing may run for a

few days consecutively and then stop until the next batch of material is ready to process. The

contractor estimates that based on 8 hours of crushing per day, there will need to be a total of 21

days of crushing activity, not necessarily in one consecutive period of time. In order to account for

possible mechanical maintenance or other contingency, the requested number of days of operation

is 28 days.

DUST MITIGATION

Most of the newer mobile crushing plants have built in “wash bars” that introduce water into the

material during crushing. This dampens the dust at the source and reduces wind borne dust

migrating from the crushing plant. In the case that the crusher plant available to the site does not

have this built in dust suppression system, the contractor has committed to apply water manually

to the material prior to crushing and after it has been produced. It should be noted that this is a

large site that will regraded in its entirety. Dust suppression throughout construction will follow

standard procedures but elimination of dust is not possible. The contributory dust from the

crushing operation is not anticipated to make the overall level of dust on the site any worse than

normal construction practices would dictate.

NOISE IMPACTS

WSP has collected some limited data on rock crushers and has reviewed published data on other

construction equipment such as large bulldozers and excavators that would be commonly used on

a construction site such as Costco’s. Noise data differs between brands for the same type of

equipment and the mechanical condition of the machines can also provide variable noise

emissions. The contractor for Costco has also provided recent data from a quarry in Vernon that

supports the publicly available data but suggests that the noise levels are generally lower than the

published data.

Our general finding is that a typical bulldozer or excavator emits between 80 and 90 decibels

during normal operations. These pieces of equipment are mobile and will move around the site

during operations. As such, the distance from the equipment to the adjacent residential will be

constantly changing.

The rock crusher will be placed in one location and may move once or twice during the entire

duration of the crushing operation. Therefore, we can assure that the placement of the machine can

Page 3

be done in a way to maximise separation from the residential use. The data we have on rock

crushers show that, immediately adjacent to the machine, noise emissions are between 90 and 99

decibels. However, we also have data of the noise level at a 20 m separation which ranges from 74

to 85 decibels. Given that the crushing plant will not be located closer than 50 m from residential,

the noise levels will be significantly less than at the 20 m data measurements. In terms of

comparative noise emission experienced by adjacent residential users, the crushing plant will not

produce any greater impact than other machinery being used and accepted as common

construction activity.

The more recent data collected from the Quarry in Vernon suggested that the noise levels at 20 m

distance from the machine were in the range of 70-75 decibels and at 50 m, they were as low as 62

decibels.

As a final note, all mobile equipment is required to use movement awareness beepers as a safety

precaution. These beepers are, by design, louder than the operating equipment and produce noise

emissions in the range of 90-110 decibels.

ENVIRONMENTAL AND EFFICIENCY CONSIDERATIONS

As previously noted, the estimated volume of oversized material that would be processed on site is

approximately 4,500 cubic metres which is the equivalent of approximately 320 tandem dump

truck loads. If the material cannot be processed on-site, it has to be removed from the site. The two

closest gravel pits to export this material to are either in West Kelowna (12 kms) or Lake Country

(17 km). Considering round trips to haul to the pit and return to site, this equates to between 7,680

to 10,880 kms of truck trips that could be eliminated by the on-site processing.

In terms of efficiency, not only does the on-site processing eliminate the truck trips to export the

material, but it facilitates a waste material being converted into a useable and necessary product

for the construction. Aggregates of all kinds are a valuable and non-renewable resource and every

effort should be made to use them as efficiently as possible.

CONCLUSION

This application for a Temporary Use Permit is being submitted to allow for a rock crushing plant

to be used on the new Costco Warehouse site intermittently for a total duration of 28 days during

the construction in 2021. The hours of operation are proposed to be the same as for the rest of the

equipment on site and regulated by the City of Kelowna Noise Bylaw.Mitigation measures will be

applied to reduce dust and we propose that the noise impacts will be no greater than other

machinery used under accepted construction practises. Furthermore, the operation of the crusher

on site will provide efficiency and reduce environmental impacts by eliminating between 7,680

and 10,880 kilometers of truck travel on local roads.

Andrew Bruce

Practice Lead, Private Development

SCHEDULE A

v

v

v

v

v

v

EX. 300m

m PERF. PVC STM

EX. 3

00mm

PER

F. P

VC S

TM

EX. 300mm PERF. PVC STM

EX. 2

400x

2400

CON

C ST

M BOX C

ULV.

EX. 2400x2400 CONC STM BOX CULV.

EX. 2400x2400 CONC STM BOX CULV.

EX. 7

50mm

PVC

SAN

EX. 2

00mm

PVC

WAT

EX. 200mm PVC WAT

EX. 750mm PVC SAN

EX. 200m

m PVC WAT

EX. 200m

m PVC SAN

EX. 750m

m PVC SANEX. 250mm PVC W

AT

900m

m PE

RF S

TM

900mm PERF STM

900m

m PERF S

TM

900mm PERF STM

150mm PVC STM

150mm PVC STM

525m

m PV

C ST

M52

5mm

PVC

STM

450mm PVC STM450mm PVC STM

450mm PVC STM450mm PVC STM

525mm PVC STM525mm PVC STM

525m

m PV

C ST

M

525mm PVC STM

750mm PERF S

TM

750mm PERF STM

750mm PERF STM150mm PVC STM

300m

m PV

C ST

M25

0mm

PVC

STM

250mm PVC STM

900mm PERF STM900mm PERF STM

200mm PVC SAN 200mm PVC SAN

200mm PVC SAN

200m

m PV

C SA

N 20

0mm

PVC

SAN

200mm PVC WAT 200mm PVC WAT

200m

m PVC WAT

200m

m PV

C W

AT 20

0mm

PVC

WAT

200mm PVC WAT

200mm PVC WAT 200mm PVC WAT

200mm PVC WAT

200m

m PV

C W

AT

200m

m PV

C W

AT

200m

m PV

C W

AT

200m

m PVC W

AT

200m

m PVC W

AT

200m

m PV

C W

AT 20

0mm

PVC

WAT

PLOT

TED:

2021

-02-

02 -

11:38

AM

FILE

: p:\2

017\1

7m-0

2290

-01 k

elown

a bar

on ro

ad -

reloc

ate\3_

tech\3

_cad

d\3_s

heets

\05 -

on-si

te\wa

reho

use\1

7m-0

2290

-01-

05-w

h-c1

_site

_plan

s.dwg

CTB:

wsp

_bc_

int-p

artia

lcolou

r.ctb

PROJECT:

TITLE:

CLIENT:

CLIENT REF. #:

REVISION:

DESCRIPTIONDATEREV

DISCIPLINE:

25mm

IF THIS BAR IS NOT25mm LONG, ADJUST

YOUR PLOTTING SCALE.

DATE:

PROJECT NUMBER:

SEAL:

DISCLAIMER: COPYRIGHT:THIS DRAWING AND DESIGN IS COPYRIGHT PROTECTED WHICH SHALL NOT BE USED,REPRODUCED OR REVISED WITHOUT WRITTEN PERMISSION BY WSP. THE CONTRACTORSHALL CHECK AND VERIFY ALL DIMENSIONS AND UTILITY LOCATIONS AND REPORT ALLERRORS AND OMISSIONS PRIOR TO COMMENCING WORK.

BY

ORIGINAL SCALE:

DESIGNED BY:

DRAWING NUMBER: REV.

MODIFIED BY:

DRAWN BY:

APPROVED BY:

ASSISTED BY:

N

F F F

F

T | www.wsp.com

WSP Canada Inc.700-1631 Dickson Ave, Kelowna, BC V1Y 0B5

250-980-5500

17M-02290-01-05

--

COSTCO KELOWNAWAREHOUSE

COMPOSITE UTILITY PLAN

C103 3A

1:500

S. Cadieux, P.Eng.

S. Springstead, GradTech

S. Springstead, GradTech

K. Unger, GradTech

S. Cadieux, P.Eng.

2020-11-20

INFRASTRUCTURE

TITL

E BL

OCK

VERS

ION

1.0

0 5 25m1:500

BARO

N RD

LECKIE RD

SPRINGFIELD RD

ELECTRICAL SERVICE CONNECTION.REFER TO SHALLOW UTILITY

DRAWINGS FOR DETAILS.

STORM SERVICECONNECTION. REFER TODWG C501 FOR DETAILS.

GAS SERVICE CONNECTION.REFER TO FORTIS DRAWINGS

FOR DETAILS

WATER SERVICECONNECTION. REFER TODWG C503 FOR DETAILS.

SANITARY SERVICECONNECTION. REFER TODWG C502 FOR DETAILS.

STORM SERVICECONNECTION. REFER TODWG C501 FOR DETAILS.

REFER TO MECHANICALDRAWINGS LIGHTING DETAILS

SIGNALED INTERSECTION(BY OTHERS)

1A 2021-01-15 ISSUED FOR 90% DESIGN REVIEW SDS

GAS METER.REFER TO FORTISDRAWINGS FOR DETAILS

PROPOSED GAS MAIN EXTENSIONCROSSES DRIVEWAY. CONTRACTOR

TO COORDINATE WITH FORTIS.

PROPOSED GAS MAIN EXTENSIONCROSSES DRIVEWAY. CONTRACTOR

TO COORDINATE WITH FORTIS.

LEGEND:

LIMITS OF CONSTRUCTION

2A 2021-02-01 ISSUED FOR BUILDING PERMIT SDS

COMMUNICATION SERVICECONNECTION. REFER TO SHALLOWUTILITY DRAWINGS FOR DETAILS.

3A 2021-02-01 ISSUED FOR OWNERS REVIEW SDS

v

v

v

v

v

v

PLOT

TED:

2021

-02-

02 -

11:36

AM

FILE

: p:\2

017\1

7m-0

2290

-01 k

elown

a bar

on ro

ad -

reloc

ate\3_

tech\3

_cad

d\3_s

heets

\05 -

on-si

te\wa

reho

use\1

7m-0

2290

-01-

05-w

h-c2

_esc

.dwg

CTB:

wsp

_bc_

int-fu

llblac

k.ctb

PROJECT:

TITLE:

CLIENT:

CLIENT REF. #:

REVISION:

DESCRIPTIONDATEREV

DISCIPLINE:

25mm

IF THIS BAR IS NOT25mm LONG, ADJUST

YOUR PLOTTING SCALE.

DATE:

PROJECT NUMBER:

SEAL:

DISCLAIMER: COPYRIGHT:THIS DRAWING AND DESIGN IS COPYRIGHT PROTECTED WHICH SHALL NOT BE USED,REPRODUCED OR REVISED WITHOUT WRITTEN PERMISSION BY WSP. THE CONTRACTORSHALL CHECK AND VERIFY ALL DIMENSIONS AND UTILITY LOCATIONS AND REPORT ALLERRORS AND OMISSIONS PRIOR TO COMMENCING WORK.

BY

ORIGINAL SCALE:

DESIGNED BY:

DRAWING NUMBER: REV.

MODIFIED BY:

DRAWN BY:

APPROVED BY:

ASSISTED BY:

N

F F F

F

T | www.wsp.com

WSP Canada Inc.700-1631 Dickson Ave, Kelowna, BC V1Y 0B5

250-980-5500

17M-02290-01-05

--

COSTCO KELOWNAWAREHOUSE

EROSION & SEDIMENT CONTROLCONSTRUCTION STAGE

C201 3A

1:500

S. Cadieux, P.Eng.

S. Springstead, GradTech

S. Springstead, GradTech

K. Unger, GradTech

S. Cadieux, P.Eng.

2020-11-20

INFRASTRUCTURE

TITL

E BL

OCK

VERS

ION

1.0

0 5 25m1:500

NILEX SILT FENCE TO BE INSTALLED AROUNDSITE PERIMETER PRIOR TO CLEARING/GRUBBING.INSTALLATION AS PER DETAIL A, DWG C203.MAINTENANCE AS PER DRAWING NOTES.

TEMPORARY SITE ACCESS POINTS TO BECLEAN GRANULAR MATERIAL IN ORDER TOMITIGATE SEDIMENT TRANSFER OFFSITE.

TEMPORARY SITE ACCESS POINTS TO BECLEAN GRANULAR MATERIAL IN ORDER TOMITIGATE SEDIMENT TRANSFER OFFSITE.

TEMPORARY SITE ACCESS POINTS TO BECLEAN GRANULAR MATERIAL IN ORDER TOMITIGATE SEDIMENT TRANSFER OFFSITE.

TEMPORARY SITE ACCESS POINTS TO BECLEAN GRANULAR MATERIAL IN ORDER TOMITIGATE SEDIMENT TRANSFER OFFSITE.

SILT FILTER TO BE INSTALLEDPRIOR TO TIE-IN TO EXISTING STORM SYSTEM.INSTALLATION AS PER DETAIL B, DWG C203.MAINTENANCE AS PER DRAWING NOTES. (TYP.)

PROTECT EXISTING CATCH BASINS

1A 2021-01-15 ISSUED FOR 90% DESIGN REVIEW SDS

BARO

N RD

LECKIE RD

PROTECT EXISTING CATCH BASINS

PROTECT EXISTING CATCH BASINS

CONSTRUCTION ACCESSROAD BY COSTCO GC

7.60m

METAL BUILDING AREA80m X 35m

MIN. 30000 SQ.FT.TO BE PROVIDEDBY COSTCO GC

WINTERCAP 375.20m (FFE)

BUILDING PAD 374.90m

MAX 2:1 SLOPE

2A 2021-02-01 ISSUED FOR BUILDING PERMIT SDS

NILEX SILT FENCE

LEGEND:

INFILTRATION DITCH

TEMPORARY INFILTRATION DITCH TO BE0.5m BELOW CONSTRUCTION ACCESS ROAD

3A 2021-02-01 ISSUED FOR OWNERS REVIEW SDS

SCHEDULE 1 Site Profile

Version 4.0

–1–

Introduction Under section 40 of the Environmental Management Act, a person who knows or reasonably should know that a site has been used or is used for industrial or commercial purposes or activities must in certain circumstances provide a site profile. Schedule 2 of the Contaminated Sites Regulation sets out the types of industrial or commercial purposes or activities to which site profile requirements apply. If section 40 of the Environmental Management Act applies to you and you know or reasonably should know that the site has been used or is used for one of the purposes or activities found in Schedule 2 of the Contaminated Sites Regulation, you may be required to complete the attached site profile.

Notes/Instructions:

Persons preparing a site profile must complete Section I, II and III, answer all questions in sections IV through IX, and sign section XI. If the site profile is not satisfactorily completed, it will not be processed under the Environmental Management Act and the Contaminated Sites Regulation. Failure to complete the site profile satisfactorily may result in delays in approval of relevant applications and in the postponement of decisions respecting the property.

The person completing this site profile is responsible for the accuracy of the answers. Questions must be answered to the best of your knowledge.

Section 27 (1) of the Freedom of Information and Protection of Privacy Act requires that provision of personal information concerning an individual must be authorized by that individual. Persons completing the site profile on behalf of the site owner must be authorized by the site owner.

One (1) site profile may be completed for a site comprised of more than one titled or untitled parcel, but individual parcels must be identified.

The latitude and longitude (accurate to 0.5 of a second using North American Datum established in 1983) of the centre of the site must be provided. Also, please attach an accurate map, containing latitude, longitude and datum references, which shows the boundaries of the site in question. Please use the largest scale map available.

If the property is legally surveyed, titled and registered, then all PID numbers (Parcel IDentifiers – Land Title Registry system) must be provided for each parcel as well as the appropriate legal description.

If the property is untitled Crown land (no PID number), then the appropriate PIN numbers (Parcel Identification Numbers – Crown Land registry system) for each parcel with the appropriate land description should be supplied.

If available, the Crown Land File Number for the site should also be supplied.

Anything submitted in relation to this site profile will become part of the public record and may be made available to the public through the Site Registry as established under the Environmental Management Act.

Under section 43 of the Environmental Management Act, corporate and personal information contained in the site profile may be made available to the public through the Site Registry. If you have questions concerning the collection of this information, contact the Site Registrar, at site@gov.bc.ca. For questions on site profiles, please send a message to siteprofiles@gov.bc.ca.

–2–

I CONTACT IDENTIFICATION

A. Name of Site Owner: Last First Middle Initial(s) (and/or, if applicable)

Company

Owner’s Civic Address

City____________________________________________Province/State

Country_________________________________________Postal Code/ZIP

B. Person Completing Site Profile (Leave blank if same as above): Last First Middle Initial(s) (and/or, if applicable)

Company

C. Person to Contact Regarding the Site Profile: Last First Middle Initial(s) (and/or, if applicable)

Company Mailing Address

City Province/State

Country Postal Code/ZIP

Telephone (______) ______ - __________ Fax (______) ______ - __________

II SITE IDENTIFICATION

Please attach a site location map

All Property Coordinates (using the North American Datum 1983 convention) for the centre of the site: Latitude: Degrees Minutes Seconds Longitude: Degrees Minutes Seconds Please attach a map of appropriate scale showing the boundaries of the site. For Legally Titled, Registered Property Site Street Address (if applicable) City Postal Code

–3–

PID numbers and associated legal descriptions. Attach an additional sheet if necessary. PID Legal Description Total number of titled parcels represented by this site profile is: _______ For Untitled Crown Land PIN numbers and associated Land Description. Attach an additional sheet if necessary. PIN Land Description Total number of untitled crown land parcels represented by this site profile is:

(and, if available) Crown land file numbers. Attach an additional sheet if necessary.

III COMMERCIAL AND INDUSTRIAL PURPOSES OR ACTIVITIES

Please indicate below, in the format of the example provided, which of the industrial and commercial purposes and activities from Schedule 2 have occurred or are occurring on this site.

EXAMPLE Schedule 2 Description Reference E1 appliance, equipment or engine repair, reconditioning, cleaning or salvage F10 solvent manufacturing or wholesale bulk storage Please print legibly. Attach an additional sheet if necessary Schedule 2 Description Reference

–4–

IV AREAS OF POTENTIAL CONCERN

Is there currently or to the best of your knowledge has there previously been on the site any (please mark the appropriate column opposite the question):

YES NO

A. Petroleum, solvent or other polluting substance spills to the environment greater than 100 litres?

B. Residue left after removal of piled materials such as chemicals, coal, ore, smelter slag, air quality control system baghouse dust?

C. Discarded barrels, drums or tanks?

D. Contamination resulting from migration of substances from other properties?

V FILL MATERIALS

Is there currently or to the best of your knowledge has there previously been on the site any deposit of (please mark the appropriate column opposite the question):

YES NO

A. Fill dirt, soil, gravel, sand or like materials from a contaminated site or from a source used for any of the activities listed under Schedule 2?

B. Discarded or waste granular materials such as sand blasting grit, asphalt paving or roofing material, spent foundry casting sands, mine ore, waste rock or float?

C. Dredged sediments, or sediments and debris materials originating from locations adjacent to foreshore industrial activities, or municipal sanitary or stormwater discharges?

VI WASTE DISPOSAL

Is there currently or to the best of your knowledge has there previously been on the site any landfilling, deposit, spillage or dumping of the following materials (please mark the appropriate column opposite the question):

YES NO

A. Materials such as household garbage, mixed municipal refuse, or demolition debris?

B. Waste or byproducts such as tank bottoms, residues, sludge, or flocculation precipitates from industrial processes or wastewater treatment?

C. Waste products from smelting or mining activities, such as smelter slag, mine tailings, or cull materials from coal processing?

D. Waste products from natural gas and oil well drilling activities, such as drilling fluids and muds?

E. Waste products from photographic developing or finishing laboratories; asphalt tar manufacturing; boilers, incinerators or other thermal facilities (e.g. ash); appliance, small equipment or engine repair or salvage; dry cleaning operations (e.g. solvents); or from the cleaning or repair of parts of boats, ships, barges, automobiles or trucks, including sandblasting grit or paint scrapings?

–5–

VII TANKS OR CONTAINERS USED OR STORED, OTHER THAN TANKS USED FOR RESIDENTIAL HEATING FUEL

Are there currently or to the best of your knowledge have there been previously on the site any (please mark the appropriate column opposite the question):

YES NO

A. Underground fuel or chemical storage tanks other than storage tanks for compressed gases?

B. Above ground fuel or chemical storage tanks other than storage tanks for compressed gases?

VIII HAZARDOUS WASTES OR HAZARDOUS SUBSTANCES

Are there currently or to the best of your knowledge have there been previously on the site any (please mark the appropriate column opposite the question):

YES NO

A. PCB-containing electrical transformers or capacitors either at grade, attached above ground to poles, located within buildings, or stored?

B. Waste asbestos or asbestos containing materials such as pipe wrapping, blown-in insulation or panelling buried?

C. Paints, solvents, mineral spirits or waste pest control products or pest control product containers stored in volumes greater than 205 litres?

IX LEGAL OR REGULATORY ACTIONS OR CONSTRAINTS

To the best of your knowledge are there currently any of the following pertaining to the site (please mark the appropriate column opposite the question):

YES NO

A. Government orders or other notifications pertaining to environmental conditions or quality of soil, water, groundwater or other environmental media?

B. Liens to recover costs, restrictive covenants on land use, or other charges or encumbrances, stemming from contaminants or wastes remaining onsite or from other environmental conditions?

C. Government notifications relating to past or recurring environmental violations at the site or any facility located on the site?

X ADDITIONAL COMMENTS AND EXPLANATIONS

(Note 1: Please list any past or present government orders, permits, approvals, certificates and notifications pertaining to the environmental condition, use or quality of soil, surface water, groundwater or biota at the site.

Note 2: If completed by a consultant, receiver or trustee, please indicate the type and degree of access to information used to complete this site profile. Attach extra pages, if necessary):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

–6–

XI SIGNATURES

The person completing the site profile states that the above information is true based on the person's current knowledge as of the date completed.

Signature of person completing site profile Date completed: (YY-MM-DD)

XII OFFICIAL USE

Local Government Authority

Reason for submission (Please check one or more of the following) Soil removal

Subdivision application Zoning application Development permit Variance permit Demolition permit Date received:

Local Government contact : Name Agency Address Telephone ____________ Fax

Date submitted to Site Registrar:

Date forwarded to Director of Waste Management:

Director of Waste Management

Reason for submission (Please check one or more of the following)

Under Order Site decommissioning Foreclosure

Date received:

Assessed by: Name Region Telephone ____________ Fax If site profile entered, SITE ID #

Investigation Required? YES NO

Decision date:

Site Registrar

Date received:

Entered onto Site Registry by:

SITE ID #: Entry date: