Dry Cleaning Establishment Remediation Fund

Dry Cleaning Establishment Remediation Fund

Instructions and Application

State of Connecticut

Department of Economic and Community Development
Ronald F. Angelo, Jr., Deputy Commissioner

Don Friday, Environmental Analyst

Revised June 2008

General Description

This application will enable the DECD to determine the suitability and eligibility of an applicant to apply for financial assistance from the Dry Cleaning Establishment Remediation Fund. The application must be typewritten and include all required documents as listed in Section V or Section VI as applicable, in duplicate. Incomplete applications cannot be considered for approval. All business information accompanying this Dry Cleaning Remediation Fund Application is exempt from the Freedom of Information Act pursuant to Section 32-11(k) of the Connecticut General Statutes.

Completed applications should be delivered to the Dry Cleaning Establishment Remediation Fund, Department of Economic & Community Development, 505 Hudson Street, 4th floor, Hartford, CT 06106, and addressed to the attention of Don Fridayno later than noon on the last Friday of March (1st round) or the last Friday of August (2nd round). If you have questions, please contact Don Friday, Environmental Analyst, at (860) 270-8063. Applications not meeting these requirements cannot be approved.

Applicant:List full legal name of the applicant (either the owner/operator of the dry cleaning business or the property owner), the applicant’s mailing address, telephone and fax numbers, and Federal Employer Identification Number (FEIN) and Connecticut Tax Registration Number. If you do not have an FEIN, please list your social security number.

Dry Cleaning Business:List the full legal name of the dry cleaningbusiness. List the dry cleaning business mailing address, telephone and fax numbers. Provide FEIN/SS# and CT Tax Registration Number.

Applicant Representative:Provide the name, title, address, and telephone and fax numbers for the applicant’s representative. This could be the owner/operator of the business, if the property owner is the applicant. If another party not being the applicant will ultimately receive the funding (such as a previous business or property owner), this must be the named project representative. Provide Federal Employer Identification Number (FEIN) and Connecticut Tax Registration Number. If you do not have an FEIN, please list your social security number.

Project Information – Please provide following project information.

A. Site Information:

Activities: Identify the activities that the requested funding will beused for. You may select more than one activity.
Site Data: Include the following -
Brief written description and history of past uses of the site. Refer to the application section for the information to be included.
Groundwater classification from the most recent DEP map.
Corporate/Business Documentation: You must provide the followinginformation regarding your business:
For corporations or limited liability corporations, provide an original executed Certified Resolution of the Legislative Body.
For corporations and limited liability corporations, provide a Certificate of Good Standing/Existence obtained from the Secretary of State.
For corporations, provide the Certificate of Incorporation filed with the Secretary of State when the corporation was formed.
For limited liability corporations, provide the Articles of Organization filed with the Secretary of State when the LLC was formed.
For personal businesses, partnerships, etc., provide other documentation indicating when the business began.
Contamination Criteria:
Indicate whether existing concentrations of soil, groundwater, and/or soil vapor contamination at the site exceed the applicable criteria established in Section 22a-133k(1-3) of the Regulations of Connecticut State Agencies (RCSA) or the Remediation Standard Regulations adopted by the DEP.
Indicate whether existing concentrations of soil, groundwater, and/or soil vapor contamination off-site (resulting from releases at the site) exceed the applicable criteria established in Section 22a-133k(1-3).
Indicate whether any spill or seepage has been reported to DEP and, if so, provide the reporting date, status, and a copy of the Report.

Environmental Compliance:

A. Has any state, federal administrative agency, or court issued any order or judgment concerning a violation of any environmental law for this site? If yes, you must attach the following information:

Type of enforcement action – Identify each enforcement action as one of the following: administrative order (including consent orders), judgment, or decree.
Date – List the date each administrative order was issued or a civil or criminal action was commenced.
Jurisdiction – For each listed enforcement action, indicate whether a state or federal court or a state or federal agency was involved. Identify such court or agency.
Order/Case/Docket Number – List the order, case, or docket number of each enforcement action.
Description – Provide a brief written description of each enforcement action/violation/judgment, whether there was any penalty or compliance requirement imposed as a result of such action/violation/judgment, and the current status.
Provide all information that indicates the current status of each enforcement action/violation/judgment stated above.

B. Property Transfer Filings: Provide detailed information regardinganyand all real estate and business transfers (including transfers resulting from inheritance) since October 1985 (the effective date of the Connecticut Property Transfer Act). For each real estate and business transfer, you mustinclude all of the information listed in Section IV(4)(C) of the application. All correspondence is to be included with the applications related to transfer filings.

C. Enrollment in the DEP Voluntary Remediation Program (VRP): If applicable, provide detailed information regarding enrollment of the site in the DEP VRP, either under CGS Section 22a-133x or 22a-133y. You must include copies of all the documents listed in section IV(4)(D) of the application, including all correspondence.

Verification of compliance with the criteria and requirements in RCSA Section 22a-133k(1-3), the RSRs: If the investigation and remediation of the site is complete and an LEP has rendered a Verification attesting to such or, if the DEP has direct oversight of the site, provide a copy of the LEP verification and/or DEP approval of the investigation and remediation.
EnvironmentalLand Use Restrictions (ELURs): If applicable, provide detailed information regarding any ELURs for the site that have been, or will be in the near future, filed with DEP and the municipality.
Litigation Proceedings: Are there any outstanding litigation proceedings concerning this site? If yes, provide information on type, parties involved, and status of litigation.

B. Project Costs/Finances:

Project Description/Cost: Please complete the Project Financing Plan & Budget form. The budget form online must be used and typewritten with original signatures. Information to support all proposed project budget expenses prepared by the designated LEP must be submitted with their application. A project schedule and cash flow projection that outlines the anticipated project activities must accompany the project budget.
Applicant's Financial Contribution: The applicant must demonstrate that it has met the required deductible for the project by having invested at least $10,000 in eligible costs. Documentation required to substantiate that the deductible has been met must include, at a minimum, invoices and associated cancelled checks.

C. Responsibility for site investigation and remediation:

Identify a responsible party (e.g. current or former business owner, current or former property owner, or other party) who will undertake and complete the investigation and remediation and will be responsible for costs exceeding the approved grant.

V. Required Documents: See sections V and VI for first or subsequent year applications

Have you enclosed duplicates of the following documents?

Site Data (including all environmental reports)

Environmental Compliance Documentation/Correspondence

Project Financing Plan & Budget Summary form with project schedule and cash flow needs for the project duration.

Applicant's financial contribution, including copies of invoices and cancelled checks.

DRS dry cleaning surcharge Form OP 374 for the last four quarters prior to this application.

Corporate documents including copies of the following, as applicable, Certified Resolution of the Legislative Body, State Certificate of Existence/Good Standing, Certificate of Incorporation, and Articles of Organization. If the business is not a corporation, attach other documentation indicating the date the business began.

Executed Landlord / Tenant Agreement or another fund disbursement agreement between the applicant and the responsible party (if applicable)

Documentation from the applicant supporting needs for the grant.

APPLICANT INFORMATIONAMOUNT REQUESTED $

Applicant Name:

Applicant Mailing Address:

Telephone #: Fax #:

Email Address:

Applicant FEIN#/SS#: CT Tax Registration#:

DRY CLEANING BUSINESS INFORMATION

Establishment/Business Name:

Establishment Address:

Telephone#: Fax #:

Establishment FEIN#/SS#: CT Tax Registration#:

APPLICANT REPRESENTATIVE INFORMATION

Representative Name: Title:

Representative Address:

Telephone #: Fax#:

Email Address:

Establishment FEIN#/SS#: CT Tax Registration#:

PROPERTY OWNER INFORMATION

Property Owner Name: Title:

Property Owner Address:

Telephone#: Fax#:

Email Address:

PROJECT INFORMATION

A. Site Information

Activities

Please check off which of the following needs will be addressed by this project:

Environmental Site Assessment (Phase I, II, III ESAs) & Preparation of a Remedial Action Plan (RAP) Note: The above must be completed in accordance with the most recent Connecticut Department of Environmental Protection (DEP) Site Assessment Guidance Document, the DEP Transfer Act Site Assessment Guidance Document, and the Regulations of Connecticut State Agencies (RCSA), Section 22a-133k (1-3), (the Remediation Standard Regulations).

Site Remediation

Provision of Potable Drinking Water

Pollution Prevention

Site Data

A. Please provide a brief physical description and land use history of the site including:

(1) Historic uses (including a discussion of hazardous materials/waste handling, storage, and disposal practices);

(2) Identified and potential contamination at the site;

(3) Extent of pollution that has been identified, or may potentially be, migrating off site;

(4) Pollution impacts on public or private drinking water supply wells;

(5) Any public health and safety issues related to the site related pollution;

(6) Current operational practices; and

(7) Means and measures to prevent future spills or releases;

(8) List of all environmental reports prepared for the property site.

NOTE: Attach two copies of all available technical plans and reports related to the investigation and remediation of the site.

B. DEP Groundwater Classification & Drinking Water Supply Wells:

Please provide the groundwater classification where the Establishment is located, as indicated on the most recent DEP map.

(GAA, GA, GB, etc):

Has a drinking water supply well receptor survey been completed? Yes No

If yes, were there any wells identified? Yes No

3. Corporate Documentation

If the applicant is a corporation or a limited liability corporation, you must provide an original executed Certified Resolution of the Legislative Body.

If the applicant is a corporation, you must provide a copy of the Certificate of Incorporation filed with the Secretary of State and a copy of the Certificate of Good Standing/Existence from the Secretary of State.

If the applicant is a limited liability corporation, you must attach a copy of the Articles of Organization filed with the Secretary of State and a copy of the Certificate of Good Standing/Existence.

If the applicant is a personal business, partnership, etc., provide other documentation that indicates the date the business began.

4. Contamination Criteria

If the proposed project includes investigation and remediation activities, please complete the following:

A. Do existing concentrations of pollutants in soil, groundwater, or soil vapor at the site exceed applicable criteria established in RCSA Sections 22a-133k(1-3), the Remediation Standard Regulations (RSRs), as adopted by the DEP?

Yes No

B. Do existing concentrations of pollutants in off-site soil, groundwater, or soil vapor exceed applicable criteria established in RCSA Section 22-133k(1-3)?

Yes No Unknown

C. Has there ever been a spill or seepage of tetrachloroethylene (PCE or Perc), Stoddard solvent, or other fabric cleaning chemicals at the site?

Yes NoUnknown

If yes, was the spill or seepage reported to the DEP?

Yes – Indicate date and status:

Provide a copy of the Report.

D. Have there been spills or seepage of other pollutants on the site that will

need to be investigated or remediated? Documentation/Correspondence to be

provided as applicable.

5. Environmental Compliance

A. Has any state, federal administrative agency, or court (Federal or State) issued any order or entered any judgment concerning a violation of any environmental law? (This applies to current and former property and business owners.)

Yes No

If yes, attach the following information: jurisdiction, type of enforcement action, date, order/case/docket number, description of violation, status, and any other pertinent information.

B. Have there been any property transfers since October 1985? Yes No

Have there been any transfers of the dry cleaning business since October 1985? Yes No

If you answered Yes to either B or C above – For each property and/or business transfer, list on a separate sheet the following information: (1) the full legal names of the transferor (seller) and the transferee (buyer), (2) the transfer date, and (3) whether or not a Property Transfer Act form was filed with DEP in accordance with CGS Section 22a-134.

For each property and/or business transfer, you must attach: (1) fully executed copies of the Transfer Act form (either Form I, II, III, or IV) and Environmental Conditions Assessment Form (ECAF) filed with the DEP and (2) copies of all correspondence from the DEP regarding confirmation of receipt of the form filing and whether the DEP delegated oversight of the investigation/ remediation to a Licensed Environmental Professional (LEP) or if the DEP retained direct oversight.

C. Has the site been enrolled in the DEP Voluntary Remediation Program (VRP) under either CGS Section 22a-133x or 22a-133y?

Yes, Date: No

If Yes – Has oversight of the investigation and remediation been delegated to an LEP by the DEP?

Yes No, DEP has retained direct oversight

If the site has been enrolled in a VRP, provide all documentation regarding enrollment, including: (1) the ECAF filed for VRP enrollment under CGS Section 22a-133x, (2) the RAP filed for VRP enrollment under CGS Section 22a-133y, and (3) all correspondence from DEP regarding receipt of the ECAF or RAP and whether DEP delegated oversight of the investigation/remediation to an LEP or if DEP retained direct oversight.

Has the investigation and remediation of the site been verified as complete in accordance with the RSRs either by an LEP or the DEP?

Yes, Date: No

If yes, provide a copy of the LEP verification report and correspondence from DEP confirming acceptance of the LEP verification or approval of the investigation and remediation, copies of any notices of intent to audit the LEP verification by DEP (if applicable), the DEP audit findings letter (if applicable), and information regarding the resolution of the DEP audit (if applicable).

Has an Environmental Land Use Restriction (ELUR) been filed with the DEP and the municipality? Yes No

If yes, provide a copy of the ELUR, the Decision Document, the land deed, and any correspondence from DEP and municipality regarding the ELUR filing.

Litigation Proceedings:

Are there any outstanding litigation proceedings related to this site?

Yes No

If yes,please provide information on type, parties involved, and status of litigation proceedings.

B. Estimated Project Cost/Finances

Project Description and Cost

Please complete the attached Project Financing Plan and Budget form. Attach detailed price quotes from at least two different goods or service providers for the project. A project schedule is to be submitted which includes estimated project costs that correspond to the budget line items. Only goods or services that are proposed at the time of application submittal and which are subsequently approved by Department of Economic and Community Development will be eligible for payment or reimbursement. The applicant must provide SEALED quotations with the application.

Applicant’s Financial Contribution

Attach invoices, cancelled checks, and receipts demonstrating that the applicant has invested at least $10,000 in eligible costs in the project.

C. Responsible party for investigation and remediation (check one). Include information to confirm the obligation of the responsible party.

Current Property Owner

Former Property Owner

Current Business Owner

Former Business Owner

Other:

V. REQUIRED DOCUMENTS – Initial funding request application:

Two sets of the following documents must be included in order for the application to be considered complete:

Site Data (including duplicates of all reports)

Environmental Compliance Documentation

Project Financing Plan & Budget Summary Form (Include payment schedule)

Applicant's Financial Contribution, including copies of invoices and cancelled checks

Connecticut dry cleaning surcharge Form OP-374 for the last four quarters

Corporate/business documents, as applicable, including a Certified Resolution of the Legislative Body, Certificate of Existence/Good Standing, Certificate of Incorporation, and Articles of Organization. If the business is not a corporation, provide other documentation indicating when the business began.

Executed Landlord / Tenant Agreement or other fund disbursement agreement (if applicable)

VI.Required Documents – All Subsequent funding request applicants:

Site Data Updates and latest environmental reports

Environmental Compliance Information

Project Financing Plan & Budget – Updated (Latest Schedule)

Last four quarters of the Connecticut Dry Cleaning Surcharge Form OP-374

Letter from applicant stating that they are current on all taxes

Correspondence and information to confirm all modifications to the approved

project.

Submittal of a Best Management Plan (BMP) in accordance with the Garment

Care Fact Sheets

Certification by Applicant and Representative