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Application for a Petroleum Contaminated SoilLand Treatment Site
APPLICATION FOR PETROLEUM CONTAMINATED SOILLAND TREATMENT SITE
(FORM A)
Guidance Document 3-04
Please refer to Minn. R. ch. 7037 for specific information on approval procedures and application requirements. Please be aware that you are required to follow the procedures set forth in the rule. Petroleum contaminated soil may be spread following receipt of Minnesota Pollution Control Agency (MPCA) Form B application approval which is contingent upon proper local notifications and approvals.
I.BackgroundMPCA Internal Use: PREO
A.Land Treatment Site Owner/AddressB.Land Treatment Site Operator/Address
Name:Name:
Street/Box:Street/Box:
City, Zip:City, Zip:
Telephone:Telephone:
- Name, relationship, and address of any person who is in possession of, has the right of control, or controls the use of real property, including without limitation a person who may be a lessee, renter, tenant, contract for deed vendor, licensee, or occupant, where the land treatment site is proposed.
D.Name, address and telephone number of person completing the application (if not listed above):
E.Legal description of Land Treatment Site: ______1/4 of ______1/4 of Section ______,
Township ______N, Range ______W, TownshipName______County ______.
Latitude/Longitude ______Collection Date______.
F.Total area for proposed land treatment (square feet or acres):
G.Has land treatment of petroleum contaminated soil occurred within
one-quarter mile of theproposed site in the last five years?YESNO
II.Site and Native Soil Characteristics
Please refer to Minn. R. ch. 7037. If necessary please consult with your local Soil Conservation Service (SCS), environmental consulting firms, or a professional soil scientist (list available upon request) in order to determine the suitability of the proposed land treatment plot for treatment of petroleum contaminated soil. Also note that a soil sample will need to be collected from the land treatment site and analyzed for organic matter percent. By signing below, you take responsibility for following Minn. R. ch. 7037 and are subject to enforcement actions if it is determined that the site is not suitable for land treatment of petroleum contaminated soil or if proper land application procedures are not followed.
III.Local Government Notification Information
Minn. R. pt. 7037.1200, subp. 3 requires notification of local governments prior to MPCA permit approval.
The chart below outlines which notifications and/or approvals are required for sites depending on their location:
CityTwspCounty / Approvals
TwspCounty
Within a city’s limits / X / X
Within the township in which the contaminated soil was generated / Organized Twsp
Unorganized Twsp / X / X
X
Within an unorganized township / X
Within an organized township / X / X
A. Approval
A land treatment site cannot accept soil batches generated from sites outside of the organized or unorganized township in which it is located unless the township or county (for unorganized townships) which has jurisdiction grants approval. Approval can be demonstrated by submittal to the MPCA of completed Form A1 which includes a copy of signed board minutes in which approval was granted. Further conditions to this approval may be added. The local board has the right to request, by resolution, that MPCA not issue a permit for soil batches which are generated outside of the organized or unorganized township in which the land treatment site is located. If the local board fails to act upon this application within 60 days of notification, the MPCA may then issue land treatment approval. See note below.
B. Notification
Local government notification is intended to provide local officials with the opportunity to notify the applicant of any local ordinances which may apply to their operation. Notification may be conducted either by obtaining the signature of an official representing the local government which has jurisdiction, or by attaching a copy of a certified mail receipt indicating that the local government has received a copy of the land treatment application. Local notification, as required in Minn. R. pt 7037.1200, subp. 3 is not intended as an approval. See note below.
Official Signature(s) of Notification:
______
Printed Name/TitleSignatureDate
______
Printed Name/TitleSignatureDate
NOTE: Land treatment of contaminated soil involves 2 separate “permits”. One to approve the “land farm” site
(Form A) and the other to approve each batch of soil applied to the site (Form B). Local government approval will be assumed to cover the Form A and all Form B applications for this site unless the MPCA is informed in writing that the township/county wishes to review and approve each Form B application of soil generated outside of the township individually. Applicants may send a copy of the application(s) by certified mail to the township/county to demonstrate to the MPCA that the 60 day review time has expired. By Minnesota Rule, a township or county board may pass a resolution requesting that the MPCA not issue a permit for the spreading of soils generated from outside of the township.
IV.Maps and Supporting Information
Attach the following to this form. CLEARLY MARK exact location of site and storage areas on each map.
A.SCS Soil Survey Information: copy of soil survey map, copies of soil survey tables or interpretation records for all soil series within the boundaries of the land treatment site.
(Note: if the county has not been mapped then a map comparable to an SCS soil survey map must be submitted for the area containing the site and storage areas. Also, include the results of any on-site investigation as described in pt. 7037.1200, subp. 2 (B)).
B.Copy of lab report for organic matter in native topsoil as required in 7037.3300, subp. 1.
organic matter percent______
C.Site map (scale: 1 inch = 200 feet).
*All applicable site and soil characteristics as described in Minn. R. pts. 7037.0900,7037.1000, 7037.1200, and 7037.3300.
D.Copy of a county plat map or comparable map with clear road directions to the site.
E.Copies of written permission, if required (e.g. adjacent land owners, if land treatment is to be done closer than 200 feet) must be included with this application.
F.In addition, please complete the following:
1.Is the site located in a 10 year flood plain? (Yes/No)
2.Are there adequate run-on controls? (Yes/No)
3.Depth to ground water or the seasonal high water table. ______(feet)
4.Is the field tiled? (Yes/No) If yes, please include a map showing the locations of the lines and indicate their approximate depths. Note that a tile drainage map is needed if the high water table is within four feet of the surface.
5.Indicate all soil types: ______
G.Copies of CountyNotifications and completed Form A1 showing Township Board resolution/approval.
V.APPLICANT SIGNATURE
By signing below you take responsibility for complying with all requirements of Minn. R.ch. 7037 “Petroleum Contaminated Soil Management” and will be subject to the contents and practices herein. The MPCA reserves the right to inspect your land treatment plot at any time and enforce through available means if it has been determined that the site was not suitable for land treatment of petroleum contaminated soil and/or if proper land application procedures have not been followed.
Land Owner Signature______Date______
Site Operator Signature______Date ______
VI.Local Officials Mailing Addresses
CountyOfficial:City, Township or Tribal Official:
Title:Title:
Street/Box:Street/Box:
City, Zip:City, Zip:
Telephone:Telephone:
Web Pages and Phone Numbers
MPCA Staff:
MPCA Toll Free:(800) 657-3864
Petroleum Remediation Program Web Page:
MPCA Information Request:
MPCA Petroleum Brownfields Program:
PetroFund Web Page:
PetroFund Phone:(651) 297-1119, or (800) 638-0418
State Duty Officer:(651) 649-5451 or (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 (800) 657-3864 (voice/TTY).
Printed on recycled paper containing at least 10 percent from paper recycled by consumers.
Guidance Document c-prp3-04: April 2005
Petroleum Remediation Program
Minnesota Pollution Control Agency
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Application for a Petroleum Contaminated SoilLand Treatment Site
CERTIFICATION OF NOTICE TO AND APPROVAL FROM [TOWNSHIP] [COUNTY] BOARD OF DIRECTORS
FOR LAND TREATMENT OF PETROLEUM CONTAMINATED SOIL
ORIGINATING FROMOUTSIDE JURISDICTION
(FORM A1)
DATE: ______
TO: ______[TOWNSHIP][COUNTY] BOARD OF DIRECTORS*
(Township name)*(If organized township, to “Township” if unorganized township, to “County”)
FROM: ______
(Applicant Name)
______
(Applicant Mailing Address)
______
[TOWNSHIP][COUNTY] BOARD OF DIRECTORS:
[I am] [We are] seeking INITIAL PREAPPROVAL (OR) TO RENEW our petroleum contaminated soil land treatment site application.
______is the land owner and ______is the operator who is responsible for the overall management of the land treatment site. All land treatment will be carried out according to Minnesota Rules Chapter 7037 as overseen by the Minnesota Pollution Control Agency.
The site is a _____ acre area located in the ____ ¼ of the ____ ¼ of Section ___, T___N, R__W, ______Township, ______County.
The ______[Township][County] Board of Directors by resolution
[grants approval] (or) [denies approval] to ______(landowner) and ______(operator) to land treat petroleum contaminated soil that originates from outside the township’s jurisdiction at the above mentioned site.
A.___ This APPROVAL applies to all soil batches to be spread at the land treatmentsite.
B.___ This APPROVAL applies to only the first batch of soil to be spread. The [Township][County] Board of Directors requests to be notified of and to approve of all subsequent batches of soil individually.
C.___ The [Township][County] Board of Directors DENIES approval of this request to land treat petroleum contaminated soil originating outside the ______Township jurisdiction. Therefore, pursuant to Minn. Stat. § 116.07, subd. 11(b), the [Township][County] Board of Directors requests that the Minnesota Pollution Control Agency not issue a permit for that purpose.
Guidance Document c-prp3-04: April 2005
Petroleum Remediation Program
Minnesota Pollution Control Agency
Page 1
Application for a Petroleum Contaminated SoilLand Treatment Site
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Land Treatment of Petroleum Contaminated SoilForm A1
This request was discussed at the ______[Township Board][CountyBoard] meeting on ______, 2_ _ _.
(Attach a copy of the minutes or resolution from the Board meeting when this preapproval or renewal application was discussed.)
______[Township][County]
Board of Directors Signatures Date
______
______
______
______
* Add more lines, if necessary
INSTRUCTIONS:
1.If your proposed land treatment site is or will be located within an organized township, this form should be directed and provided to the Township Board of Directors.If your land treatment site is or will be located within an unorganized township, this form should be directed and provided to the CountyBoard of Directors.
2.The terms in brackets are to be used alternatively. If you are certifying Notice to and Approval or Denial from a CountyBoard of Directors, strike references to the “Township” Board of Directors. If to a Township Board of Directors, strike references to “County” Board of Directors.
3.This completed form and any attachments must be submitted to the Minnesota Pollution Control Agency (MPCA) with your completed Guidance Document 3-04 Application for Petroleum Contaminated Soil Land Treatment Site (Form A). Failure to submit this form and attachments, if any, with Form A will likely delay the MPCA’s review of and decision related to your Form A Application.
Guidance Document c-prp3-04: April 2005
Petroleum Remediation Program
Minnesota Pollution Control Agency