HomeMy WebLinkAboutBinder1 NPU-GoD final 2017 Rec 020717/~-1/-/,-/31(Cr
58 INDUSTRY ROAD (0)ONDRICK Tel:413-592-2566
CHICOPEE,MA 01020 0 MATERIALS s RECYClING,LLC Fax:413-592-7451
PREQUALIFICATION INFORMATION
PETROLEUM CONTAMINATED SOILS (PCS)
The following information shall accompany all requests/submittals concerning the transport and recycling
of PCS,as governed by DEP policies in order for the facility to confirm that the pes meets its acceptance
criteria:
I.GENERATOR INFORMATION
Name:NPU;Generators On Demand
Street:260 Cherry Lane
City/Town:_O_ak_d_al_e _
II.SITE INFORMATION
Name:__S_a_m_e _
Street:_
City/Town:_
Contact:__R_o_n_S_w_a_n~ey'___
Phone:8_60_66_2_4_0_9_0 _
State/Zip:_C-=.T-=--:.0..:..63::...:7...:;0 _
Contact:_
Phone:_
State/Zip:_
Ill.ENVIRONMENTAL CONSULTANTS PERTINENT INFORMATION
Name:S_E_S_In_c _
Street:---.:6:::.:1:...:P:...:I:.=a::.:.nt=s...::D:::..:a=m:.:...::..R:::d~_
City/Town:--,E~a~s.!;.-tL!:!,yl-!-ffi.!.!:e=---_
Contact:Donald Fortunato
Phone:860 739 6691
State/Zip:_C_T_06_3_3_3 _
IV.ESTIMA TED VOLUME OF PCS:__----""'2S""'0'--_Tons___-----"'1=80"'--_CubicYards
V.BILLING INFORMATION
Name:Commercial Construction Group &
Generators On Demand
Street:61-1 Buttonball Rd
City/Town:_O_l_d_L-'-.ym_e _
Purchase Order #_
Contact:Ron Swaney
Phone:__86_0_66_2_4_0_9_0 _
State/Zip:CT 06371
VI.DESCRIPTION OF THE PCS:
___Sand Gravel Fill Clay _~X~_Other
Physical description of the PCS -In addition please indicate the presence of any
construction debris,veg.matter,ash,etc.
Soil in USDA is loamy very fine sand,muck (sapric),and gravelly fine sandy loam.
Specify type of contamination:
____Gasoline __X__Diesel ____#2 ____#4 ____#6
___Lub.Oil ____Waste Oil Jet Fuel Kerosene
Other:Virgin diesel fuel spill to soil surface-----
VII.SITE HISTORY:
Please include at a minimum the following information:
Current &Former usage of site,description of release (known dates,source),sampling method
used (grab,composite,etc.),analytical parameters selected and any other pertinent
information.
**Sufficient information must be provided in the Site History to justify the limiting of the
analytical requirements necessary for recycling.**
VIII.Please forward a diagram which includes the following information:
At least one street reference,any adjacent structures,excavation area,stockpile location,
location where samples were taken from,name of individual preparing diagram,reference the
site name and location and any other pertinent information.
IX.GENERATOR I LSP I QEP STATEMENTS:
a.I,the generatorlLSP/QEP,using due diligence have determined that there is no reason to
Suspect or believe the PCS has been impacted by any release of oil or hazardous materials
other than that of the known source or I have identified the additional oil and hazardous
materials that are suspected or known to be present in the PCS,in addition to those
associated with the known release including any anthropogenetic contaminates.
b.I,the generatorlLSP/QEP,realize that due diligence shall consist of a search of information
and records reasonably available to the generator of the PCS sufficient to make the
determination.Such records and information may include,but are not limited to,those of
the generator,location of the generation (Facility if not the generator)the Department
Bureau of Waste Site Cleanup,and the municipality (Board of Health,Fire Department)
within which the site is located.
c.1,the generator/LSP/QEP,have included sufficient information justifying the limiting of
the analytical requirements as part of the Site History Information accompanying the 21E
Bill of Lading and Material Shipping Record.This includes at a minimum the following:
i.Analytical Parameters Selected
11.Screening Data (i.e.:Total date for TCLP,Headspace)
Ill.Laboratory Analytical Data
iv.Description of the Release
v.Physical description of the soil including the classification method used.
vi.Description of the site location with regards to former and current usage.
vii.Complete Site History.
viii.Site Diagram
Generator (Print or Type Name):_R_o_n_Sw_a..".n."::;~I-~-:I-_
Generator Signature:R..:...on---,-S_w-,-a-,-ne-"Y'-+rT-7~,A.Lc....=-I-_--,-",,--_-=-Date:I0-28-2016
LSP/QEP (Print or Type.>
ILSP/QEP Signature:_--f-,/~~~-HI:,.<-~----=¥--Date:10-28-2016
ORIGINAL BILL OF LADING OR MATERIAL SHIPPING RECORD MUST BE AT THE
FACILITIES OFFICE BEFORE THE SOIL IS SHIPPED.····7"·.;~~~;~~~.D'D.«•••••••••~~~~~~••••••••••~·Z~~··a ••••••••a
Facility Representativ
Reasons for Acceptance/Refusal:_
[31'----_.-'
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor -do not
use the return
key.
~
~
Important:
This form is not
to be used for
the shipment of
remediation
wastes subject to
management
under section
310 CMR
40.0035 of the
Massachusetts
ContingencyPlannorisit tobeusedinlieuof
a hazardous
waste manifest
for hazardous
waste or
recyclable
materials subject
to theMassachusetts
Hazardous
Waste
Regulations 310
CMR 30.000.
msr.doc.doc·11/01
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Material Shipping Record &Log
For the shipment of contaminated soil,urban fill,and dredge
materials not subject to management under section 310 CMR 40.0035
nor manifesting under 310 CMR 30.000
Tracking Number
A.Location Information
1.Provide the following information on the location where the waste was generated:/tIi?tJ _./kdrtLllcA &1L~I)·h/··Iz ~J _
Release nameJ,optional)•d-~0 C!1t"rl/y Lu'J e
Street /-~Q~k.:>.L.:a4~k~··_
Cityrrown
2.
Location aidcr ,
06370
Zip code
Date/Period of generation:
3.U.S.EPA 10 number:
St~IloJ.-2Wk
To I
5.List additional tracking documents associated with this document:
4.21E release:DYes ~No
B.Generator Information
1.Provide the following generator information:.
CrCiJ era.-.for S On ])..e /J1q-'..CI1:.....cC::.!../._
Name of org~tion r"."./caa J,wtil1evcontac6!_1$i/#/Jj:/I tfc/
Street address
-=-:-----"'C"'-'--I.a.5 7L_State Zip code
~e~s-·-~-------.--------
Title OJe!Lyme
Cityrrown '
~0 -"k 2.-Lie fO
Telephone number(including extension)
C.Owner and/or Operator Information
1.If the owner and/or operator is different from the generator as indicated in Section B.provide the
following information:
Check applicable:Downer D operator
Name of organization
Contact name TItle
----------------_._----Street address
Cityrrown State Zip code
Telephone number Ext.
Material Shipping Record and Log •Page 1 of 6
msr.doc.doc·11/01
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Material Shipping Record &Log
For the shipment of contaminated soil,urban fill,and dredge
materials not subject to management under section 310 CMR 40.0035
nor manifesting under 310 CMR 30.000
Tracking Number
D.Transporter/Common Carrier Information
1.Provide the following information:
Commercial Construction Group
Transporter/Common carrier name
CT
Hazardous waste license number (if applicable)
Ron Swaney
Licensing state (if applicable)
Contact person
61-1 Bultonball Rd
Title
Street
Old Lyme 06371CT
State Zip codeCityrTown
8606624090 Ext.Telephone number
E.Receiving Facility Information
1.Provide the following information on the receiving facility:
Ondrick Materialsand Recycling,LLC
Operator/Facility name
DavidS.Costanzo Operationsand Sales Manager
TitleContactperson
58 IndustryRoad
Street
Chicopee MA 01020
Zip codeStateCityrTown
413592-2566
Ext.Telephone number
2.Type of facility:
III asphalt batch/cold mixoasphaltbatch/hot mixolandfill/disposalolandfill/daily coverothermalprocessingolandfill/structural filloother(specify):
3.Permit number:X258844
Material Shipping Record and Log·Page 2 of 6
msr.doc.doc •11101
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Material Shipping Record &Log
For the shipment of contaminated soil,urban fill,and dredge
materials not subject to management under section 310 CMR 40.0035
nor manifesting under 310 CMR 30.000
TrackingNumber
F.Description of Material
Check all that apply:
1.a.)d soil 0 dredge material 0 fill
b.Description:/l!Pcf(ilep/ie),/tJ1j1/J Y YCry6 e S~//c/,9/QYe/1j
c.Classification:D MIT ;Mu;[)A ~USAEC ~D ASEE 5q/J-:t.j/tlQ/J'f
2.D Other(describe):
3.Type of contamination:
a.0 gasoline ~diesel fuel 0 #2.oilo#15 oil 0 waste oil 0 kerosene
o #4 oilojetfuel
b.0 Debris:
D demolition 0 vegetative D inorganic AI/:J-./
c.OOther(describe):Jti.19'//)ciJ6e/6e/¥///.-;d;$0/
4.Constituents of concern (check all that apply):
OAs
OCd
OCr
DPb
DHg
DNa
DpCBs
D HVOCsoPATH
rgVOCs
DPAHs
OSNAs
:g'TPHDOther(describe):
5.Analyses performed (check all that apply):
121As D PATH.EJCd jvocs
I~§~§;(inorganic)
PCBs D TCLP (organic)
HVOCs D Other(describe):
6.Screening performed:ZI12 @ O..gce
Instrument usedj/tl[.s
Constituents
Material Shipping Record and Log.Pag<>3 of 6
rnsr.ooc.doc •11f01
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Material Shipping Record &Log
For the shipment of contaminated soil,urban fill,and dredge
materials not subject to management under section 310 CMR 40.0035
nor manifesting under 310 CMR 30.000
Tracking Number
F.Description of Material (cont.)
7.Estimated volume of materials:
./V /5tJl?tJ
Tons Other(specify units)Cubic yards
8.Contaminant source (check one):
D transportation accident
Dust b /.:
'~other(describe):/etl/fi/.J¥e'('"/Jt::='nlrar c r.J rq/IJ:r./.,-
9.Ind~cate which waste characterization support documentation is attached:jSite history information
.sampling and analytical methods/procedure
laboratory dataofieldscreening data
If supporting documentation is not appended,provide an attachment stating the date and in
connection with what document such information was previously submitted to the facility.
G.Qualified Environmental Professional Opinion
:;£5.Z/Jc'"have personally examined and am
familiar with the information
contained on and submitted with this
form.Based on this information,it is
my opinion that the testing and
assessment actions undertaken were
adequate to characterize the waste,
and that the facility or location can
accept wastes with the
characteristics described in this
submittal.I am aware that significant
penalties including,but not limited to,
possible fines and imprisonment may
result if I willfully submit information
which I know to be false,inaccurate,
or materially incomplete."
Name of aroteSSional 'C'7 L-£P
Title 5160 237 q{;'9/
Telephon
Signature
seajl/fl
Material Shipping Record and log·Page 4 of 6
-nsr.dec.doc t 1·I.'Oi
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Materiai Shipping Record &Log
For the shipment of contaminated soil,urban fill,and dredge
materials not subject to management under section 310 CMR 40.0D35
nor manifesting under 310 CMR 30.000
H.Certification of Generatol"
"I certnv under penalties of law th11l nave
personally examined and am familiar with the:
information contained in this submttal.InciLldins
eilY 3:1Cail documents accornoanvrn this
certification.and that.based on my inquiry of
those individuals immediately respcnsibie tor
obtaining the lntormat.on contained herein i:...to
the best of mv !\nov'Iiedge ano nenet.true
accurate and complete.;arn av...·aii:tni'll1ben:.
are significant penalties.incJt;d:ng.out ,:01
lirn:ted to.possible fines a:10 imprisonment fo:
wil;tu!ly submitting false tnaccurate.or
incornotete information."
./
fvlatcr:al Snlppmg Record and Log·Page;:of i5
Note:
Make additional
copies of this
page as neces-sary.
Rev.3/94
Massachusetts Department of Environmental Protection I'/-iI....';>.'..;.ZJBureauofWastePreventionI~II -/tf,;'J tl/C-,Material Shipping Record &Log T~a~~lngNUmber
For theshipment of contaminated soil,urban fill,and dredge materials not suI:!Jectto management under
section 370 C/vIR40.0035 nor manifesting under 370 CMR 30.000DLoadInformation,/~c----.,
Recer,.ing iacilily /-217
Dal~received
Timereceived
Daleor Shipment
Time01shipment
TruckfTraCIDrreglslralion
Trailerregislfation
Load sile (cubic yar6)
ton
LOAD 11:__
SignalUre ollransponer
Receiving laci/iry
Dale recaivoo
Time received
Dale oishipmen!
Time 01shipmenl
Tnx.'<!TraCiorregiSlralion
Trail/!{iegisllalion ton
LOADII:~~.
Signacure of uensponer
Receiving laciliey
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Time of shipmen,'
.trao/taao:regislralion
Trailer rrgislralion .ton
Load sae (cubic yarde
LOAD#:~
Signature ollransporler
-~~~~------------~-----Receiving laciliry
Date received
Time received'
.r"
Dale ofShipment
Time of sllioment
.."
Inxk/Iaaor regiS(rBlion
Trailer regisl!Blion ton
II Log Sheet Volume Information..2;lf~C-ton
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Page 5 of 5
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copies of this
page as neces-
,:ary.
Rev.3/9&
Massachusetts Department of Environmental Protection 1/1 "11,,,;/l{'2lf ~lJBureauofWastePreventIOn''"1/..//C .Material Shipping Record &Log
For {heshipment of contaminated soil,urban fill,and dredge materials not subject to management under
section 310 C/VIR 40.0035 nor manifesting under 370 C/viR 30.000DLoadInformation
Signarure 0;esnspon«
Reaiving idcilily
Timereaive<i
Dare01shipmenr
Time 01shipmen(
TllJClifTlaCl(}(reglsrmion
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SignaMe of rlilnspot1er
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Time received
Daleofshipmenl
Time 01silipmenl
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Tlailer rr!ljiSII/lion ton
Trar:king Number
.'
Receiving (aciliry
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Ip;;;j
Time received
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Time of shipmenr
,TI1Jck/lraclor regi slrarion
Trailer regislralion ton
load sue (cubic yard~
LOAD #:
SignalUre oIlranspOIler
Recoiving (acility
Daterecei!led
Time receive:
Dale of shipmen(
,-'------~----------------------~Time of shipmet1l
Itua/Irscto:regislralion
Trailer regis(falion ton
page.7 of __'
Page 5 of 5
Note:
~Aakgadditional
copies of this
page as neces-sary,'
Rev,3/94
Massachusetts aepartment of Environmental Protection [J'~'I'_I'U '7 "L/'C'ZJ.'Bureauof Waste Prevention t (p I 7;)7 .!
Material Shipping Record &Log
Forthe shipment of contaminated soil,urban fill,and dredge materials not subjeo to management under
section 370 CIv1R 40.0035 nor manifesting under 370 C/vIR 30,000IILoad/Ii rmation
lIeceiving iacilily
Dalerec,ived
rime received
Dale01shipment
ume oIshipmenr
Truck/Traclo(regislralion
Tlailerr19ISV8tion
Loadsize (cubic yor tons)
LOAD II:
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,Receiving faci/ilY
D'ie rcceived
Timereceived
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Time01shipment
rllJC.'t/TrfJCIOfregislralion
Trailer''E9ilvalioo ton
Tra{;klnq Number
RecEiving facility
Dale recei,'ed
Time received
Dale 01s,~ipmenl
Time 01shipment
,TruckfFraclor regiSlralion
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Load sile (cubic yard~
',/L!6a ,ton
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Dale rECeived
Time received
,Date 01shipmenl
Time 01shipmeOi
TrucXiTraClor regislfalion
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LogSheet Volume Information3;;2,trQ ton
ton
ton
pag'-of __
Page 5 of 5
Note:
Make additional
copies of this
page as neees-
sary.
Rev,3/94
Massachusetts Department of Environmental Protection !/1 ~1-/3 'C2],,"Bureauof WastePrevention'1#~if iflMaterialShippingRecord&Log
For theshipment of contaminated soil,urban fill,and dredge materials not subject to management under
section 310 C/vIR 40.0035 nor maniresting under 370 C/VIR 30,000IILoadInformation
T/merere/wi \II r I J If
DalerJS/1ipmenl is'IOU 1\"m
TimeoIshipmeni
r:5~~:5
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Timereceived
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TrailerregilValion ton
Tracking Number
LOAD II:
Signalure of Iransporrer
Receiving lacililY
Dale teceived
Time received
Dale 01shipmen!
Time of shipmenl
ttvo/trsao:regislrarion
Traiier regislralion ton
Loa.~size (cubic Y8rd'E)
LOAD#:~
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Time received
Dale of shipmen(
Time of Sl1ipmMI
Truck/Tracror regisllalion
Trailer regisllalion ton
13 Log Sheet Volume Information
q ~I ton
ton
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page,S of_
Page5 of5
Note:
Make additional
copies of this
page as neces-
sary,
Rev,3/94
Massachusetts Department of Environmental Protection r"L L«'2 t.L I ,'7-]
Bureau of Waste Prevention /"1 -:...:>T C I '
Material Shipping Record &Log rra,eking Number
For the shipment of contaminated soil,urban fill,and dredge materials not subject to management under
section 370 C/vIR 40.0.0.35nor manifesting under 370 C/VIR30,000IILoadInormation
Sir;ndliJf@vi rransponer
Receiving idcilily
Daleteceived
Timereceived /J-'7-/0
Dale01sIIipment •
860
rlflle 01shipment
Truc/I/TraCiorregistralion-,'!)2...'2J3-A
Tlailerlegislfalion /47·56 ton
load sue (cullie yareD
LOAD #:
Sigmlure of Iransponer
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Dalercccivro
Timereceived
Dale 0{shipment
TimeofShipment
Truc.VTraCiorregislralion
Trailer regiwalion ton
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Time received
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Trallel regisualion ton
page.~of __
Page 5 of 5
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Rev.3/94
Massachusetts Department of Environmental Protection ,.AV L _/U3 lJ/C~7t9
Bureau of Waste Pre ventton .~_~~~"-...;L!!..(..__...!-._l_---,L,---,,---,~,LJMaterialShippingRecord&Log
For the shipment of contaminated soil,urban fill,and dredge materials not subiect to management under
section 310 CIv1R 40.0035 nor manifesting under 370 CMR 30.000IIL0eBlnformation
LOAD ~.\n./L_----F
Signature oloansponer
Receiving iaciliry
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Trar:xinq Number
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II Log Sheet Volume Information
.0.ton
ton
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pag~of __
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copies of this
page as neces-sary.
Rev.3)94
Massachusetts Department of Environmental Protection r 11 ...-1J /113 L£/:LJBureauofWastePrevention'10 11'--7 7 J G .Material Shipping Record &Log Trarking Number
For the shipment of contaminated soil,urban fill,and dredge materials not subject to msneqetnent under
section 310 C/vIR 40.0035 nor manifesting under 370 C/vIR 30.000IILoadInrmation
LOA
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lime received It VZ'f6
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[Old 5il~(waie yareD
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LOAD '~='====:;2~----
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13 Log Sheet Volume Information
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pagl-of__._
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copies of this
page as neces-
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Massachusetts Oepartment of Environmental Protection
Bureau of WastePrevention·Material Shipping Record &
For the shipment of contaminated soil,urban fill,end dredge materials not subject to management under
section 370 CIv1R40.0035 nor manifesting under 370 CMR 30.000IILoadInformation
Receiving hleilily
DiUereceived
TimerKliVPd
Dale IXSI1ipment I
/0\.30
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LOAD II:
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Time received -
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page.~of .__.
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