RSA 146-A/Env-Or 605.06 NHDES Site #: Project

NHDES-S-04-011

INITIAL RESPONSE ACTION REPORTING FORM

This form shall used to document initial response actions conducted at petroleum spill sites. This form is designated to provide NHDES with adequate information to determine if additional corrective actions and/or monitoring will be required prior to site closure.

RSA 146-A/Env-Or 605.06 NHDES Site #: Project #:

2016-01-01Waste Management Division - Oil Remediation and Compliance Bureau Page 1 of 2

(603) 271-3899 www.des.nh.gov

PO Box 95, Concord, NH 03302-0095

NHDES-S-04-011

A. Release Location Information

Site Information Property Owner Information

Site Name: Owner Name:

Responsible Party Name: Owner Address:

Site Address:

Contact Person:

Contact Person: Daytime Phone:

Daytime Phone: Notes:

2016-01-01Waste Management Division - Oil Remediation and Compliance Bureau Page 1 of 2

(603) 271-3899 www.des.nh.gov

PO Box 95, Concord, NH 03302-0095

B. Consultant/Contractor Information

Company Name:

Mailing Address:

Contact Person:

Daytime Phone:

C. Potential Receptor Information (check all that apply)

Yes No Yes No

☐ ☐ Municipal Water in Area ☐ ☐ Municipal Sewer Service

☐ ☐ Municipal Water Provided to Site ☐ ☐ Water Supply Well On-Site

☐ ☐ Within Wellhead Protection Area Available Well Information

☐ ☐ Surface Water Body Within 100’

D. Spill Information (check all that apply)

☐ Aboveground Storage Tank (AST) spill/release Type of Product: Quantity of Product Lost: Gallons

☐ Underground Storage Tank (UST) spill/release ☐ #2 Fuel Oil Other Information:

☐ Residential Home Heating Oil Release ☐ Kerosene

☐ Release to Surface Water ☐ Diesel Fuel

☐ Free Product Present ☐ Gasoline

☐ Transportation Accident ☐ Hydraulic Oil

☐ Indoor Air Vapors Present ☐ Used Oil

☐ Other: ☐ Other:

E. Corrective Action Information (check all that apply)

☐ Soil Disposal Quantity (units): ☐ Vapor Abatement Measures

☐ Drums ☐ Truck ☐ Rolloff ☐ Sub-slab venting ☐ Other:

☐ Free Product Recovery Quantity (units): ☐ Surface Water Protection Measures

☐ Drums ☐ Vacuum Truck ☐ Boom ☐ Pads

Narrative Summary of Corrective Actions:

F. Investigation Information (check all that apply)

☐ Soil Sampling ☐ Drinking Water Sampling ☐ Indoor Air Sampling

☐ Groundwater Sampling ☐ Monitoring Well/Boring Installation ☐ Other:

Additional Information:

G. Summary of Soil Analytical Data
Sample ID / Soil Remediation Standards (mg/kg)
Sample Date
Depth (ft)
PID Reading / --
TPH / 10,000
Benzene / 0.3
Toluene / 100
Ethylbenzene / 140
Total Xylenes / 500
Naphthalene / 5
2-Methylnaphthalene / 96
sec-Butylbenzene / 130
Isopropylbenzene / 330
n-Propylbenzene / 85
1,2,4-trimethylbenzene / 130
1,3,5-trimethylbenzene / 96
H. Summary of Water Analytical Data
Sample ID / AGQS
(mg/L)
Sample Date
Benzene / 5
Toluene / 1,000
Ethylbenzene / 700
Total Xylenes / 10,000
Naphthalene / 20
2-Methylnaphthalene / 280
sec-Butylbenzene / 260
Isopropylbenzene / 800
n-Propylbenzene / 260
1,2,4-trimethylbenzene / 330
1,3,5-trimethylbenzene / 330

I. Attachments

☐ Site Sketch (required) ☐ Laboratory Data ☐ Groundwater Contour Plan

☐ Site Photos (required) ☐ Disposal Receipts (required) ☐ Boring Logs/Well Construction Details

F. Recommendations:

2016-01-01Initial Response Action Report Form Page 2 of 2