Application to Thermally Treat Petroleum Contaminated Soil

Application to Thermally Treat Petroleum Contaminated Soil

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APPLICATION TO THERMALLY TREAT

PETROLEUM CONTAMINATED SOIL

Guidance Document 3-11

I.Minnesota Pollution Control Agency (MPCA) Site ID Number: LEAK#

II.MPCA Project Manager:

III.Source of Soil:

Facility Name:

Street Address:

City, State, Zip:

Contact Name:

Telephone:

IV. Date of Soil Excavation:

V.Contamination Details:

Weight of Soil (tons): (One cubic yard of soil is approximately equivalent to 1.4 tons.)

Type Petroleum Contamination:

Gasoline, diesel fuel, No. 1 fuel oil, No. 2 fuel oil, kerosene, aviation gas, used oil, (hydraulic

fluid, cutting oil, motor oil, quench oil).

Contaminant Concentration (mg/kg)*

ATTACH LABORATORY ANALYTICAL SHEETS

Benzene
Toluene
Ethyl Benzene
Xylene
Total Lead
Total Hydrocarbons
GRO/DRO
Soil Type (sand, silt, clay, etc.)

*Note:See Petroleum Remediation Program Guidance Document 4-04Soil Sample Collection and Analysis Procedures for additional necessary analysis.

VI.Thermal Treatment Unit

Name:

Address:

(if portable, where will plant be located)

City, State, Zip:

Plant Number or Model:

(If portable, separation distance in feet from nearest residence(s):.)

Contact Name:Title:

Telephone: Site Telephone:

Air Quality Permit Number:

______

DateSignature of Authorized Thermal Treatment

Unit Representative Accepting Soil

VII.Date treatment will be completed:

VIII.Individual Submitting Request:

Company Name:

Address:

City, State, Zip:

Contact Name:

Telephone:

Signature:

Date:

This completed application, if confirmed by the monthly thermal treatment facility log, constitutes an acceptable soil corrective action plan. The individual submitting the request and the authorized thermal treatment unit representative certify that soil contaminant concentrations fall within the limits established in Guidance Document 3-10Thermal Treatment of Petroleum Contaminated Soil and that the thermal treatment facility is operating in compliance with its Air Quality emission permit.

Mail to the MPCA project manager. For the correct address, see the MPCA web page below.

Web pages and phone numbers

MPCA staff

MPCA toll free1-800-657-3864

Petroleum Remediation Program web page

MPCA Infor. Request

PetroFund Web Page

PetroFund Phone651-297-1119, or 1-800-638-0418

State Duty Officer651-649-5451 or 1-800-422-0798

Upon request, this document can be made available in other formats, including Braille, large print and audio tape. TTY users call 651/282-5332 or Greater Minnesota 1-800/657-3864.

Printed on recycled paper containing at least 10 percent fibers from paper recycled by consumers.

Guidance Document c-prp3-11: April 2005

Petroleum Remediation Program

Minnesota Pollution Control Agency