79 Elm St. Hartford, CT 06106-5127 (860) 424-3705 portal.ct.gov/DEEP/remediation

VOLUNTARY REMEDIATION (§22a-133x)

VERIFICATION (Release Area)

Please refer to the Verification Form Instructions for more information on how to fill out and submit this form properly. The address and Rem# in the headers will automatically update upon printing (including printing to pdf) or print-previewing. Yellow fields are mandatory.

DEEP Use Only	Date Received:	Outcome
Verification #:
Rem #: Rem #

Part I: General Information

Property Name (current or former name) Property Name	This property is described in the land records of:
Property Street Address Property Address	Tax Assessor Town Tax Assessor Town
City/ Town City/Town	State CT	ZIP 00000	Lot/Parcel ID Lot/Parcel	Block Block	Map Map	Total Acreage Acres
☐ The subject release area is clearly demarcated on the class A-2 or similarly accurate survey attached as Exhibit 1 and is described in the verification report.

Licensed Environmental Professional (LEP)	22a-133x Applicant
Name Name	Name of Signatory for Applicant Name
Company Company Name	Applicant Applicant
Address Address	Address Address
City/Town City/Town	State State	Zip 00000	City/Town City/Town	State State	Zip 00000
Phone Phone	Phone Phone
E-mail E-mail	E-mail E-mail

Part II: Verification Information

This verification pertains to the following Environmental Condition Assessment Form (ECAF) filed with the Department : Rem # Rem # Date of ECAF Filing mm/dd/yyyy (Date received by the Dept.)	Applicable Date of this Verification This is the date that the LEP signs the verification. Click print preview to automatically populate the LEP signature date with the date entered here.	mm/dd/yyyy
Prior Property Transfer Filings to be Closed with this Verification (if any) Rem #s

LEP Certification	22a-133x Applicant Certification
"I verify pursuant to §22a-133x of the CGS and §22a-133v-1(z) of the RCSA, that an investigation has been performed at the subject portion of the property in accordance with prevailing standards and guidelines, and that, at the time of this verification… (select one)	“In accordance with §22a-133x(e) of the CGS, I submit this Verification that has been signed and sealed by a licensed environmental professional (LEP), and the attached 133x Release Area Verification Report, which has been approved in writing by a LEP, and other applicable documentation.
The subject release area is in compliance with the remediation standards (RCSA §22a-133k-1 - 22a-133k-3 without requiring remediation."
The subject release area has been remediated in accordance with the remediation standards (RCSA §22a-133k-1 - 22a-133k-3)."
LEP Signature	Applicant Authorized Signature
LEP Printed/Typed Name Name	Applicant Authorized Signatory Printed/Typed Name Name
Date of LEP Signature (Auto-Fill) mm/dd/yyyy	Date of Applicant Signature
LEP Seal	License # Number

Part III: Setting and Receptors

A. Environmental & Cultural Setting
Groundwater Classification:	GW Class	Surface Water Classification:	SW Class
Depth to Water Table:	Depth	Nearest Downgradient Surface Water Body:	SW Name
Depth to Bedrock:	Depth	Distance to Surface Water Body Named Above:	Distance
Abutting Land Uses: (check all that apply)	☐ Industrial □ Commercial □ Residential □ Agricultural □ Undeveloped

B. Receptors
1. Sensitive Receptor Land Use
Sensitive Receptor Land Use Within 500 Feet of the Site: (check all that apply)	☐ School ☐ Recreational ☐ Residential ☐ Child Care Facility ☐ Healthcare Facility ☐ Sensitive Water Resource (e.g. shellfish beds, public fishing areas, significant wetland complexes, public water supplies) ☐ Other (specify): Describe

2. Water Supply Wells
Has site groundwater been contaminated?	☐ Yes ☐ No
Number of water supply wells within 500 ft. of site boundaries (including site well)	Enter Number
Has an on-site groundwater plume migrated off-site?	☐ Yes ☐ No
Water Supply Well Receptor Survey submitted to the Commissioner:	☐ Yes ☐ No
Number of water supply wells impacted by on-site releases:	Enter Number
Number of locations requiring alternative permanent potable water supply:	Enter Number
Permanent potable water supply provided by:
☐ Water main connection	Date:	mm/dd/yyyy
☐ Filtration	Monitoring Frequency:	Frequency
Comments:	Enter text as needed.

3. Vapor Intrusion
Have groundwater volatilization criteria been exceeded anywhere on-site?	☐ Yes ☐ No
Number of occupied buildings overlying plume:	Enter Number
Have risks been mitigated:	☐ Yes ☐ No ☐ Not applicable
Comments:	Enter text as needed.

4. Ecological Receptors
Were the potential ecological exposure pathways, where contaminants could affect aquatic and terrestrial life, evaluated?	☐ Yes ☐ No
What level of evaluation was completed?	☐ None ☐ Scoping ☐ Screening ☐ Risk Assessment
Did any on-site release have the potential to impact an ecological receptor	☐ Yes ☐ No
If yes, was the ecological receptor impacted by an on-site release?	☐ Yes ☐ No
If yes, was the ecological impact mitigated?	☐ Yes ☐ No
Comments:	Enter text as needed.

C. Significant Environmental Hazards
Was a significant hazard, as defined in 22a-6u, identified?	☐ Yes ☐ No
Significant Hazard Notification filed:	☐ Yes ☐ No ☐ Not applicable
What type(s) of hazard(s) were identified?
Click here to enter text.
Hazard Resolution (select all that apply)
☐ Commissioner’s Certification for Abatement	Enter Dates
☐ Commissioner’s Memorandum of Resolution	Enter Dates

Part IV: Compliance History and Approvals

A. Previous Remedial Program Information
Property Transfer	Rem #	Other Program
☐ Form III	Rem #	Specify Program(s)
Voluntary Remediation	Rem #
☐ 22a-133x	Rem #
☐ 22a-133y	Rem #

B. Public Notice
☐ Public notice of remediation was posted in accordance with the requirements of §22a-133x(i) and §22a-133k-1(d) of the RCSA.	Attach a copy of the public notice to this form as Appendix A and discuss any comments received in the verification report.
Public notice included the following:
☐ Remediation
☐ EURs including ELURs and NAULs
☐ Any other variance

C. Approvals & Notices Select applicable approvals and notifications. Attach copies of approvals and applicable notification forms to this form as Appendix B and discuss all notifications and required provisions in the verification report.

1. Additional Polluting Substances and Alternative Criteria
☐ Additional polluting substances criteria ☐ DEC ☐ PMC ☐ GWPC ☐ SWPC ☐ VolC	Commissioner approval date(s):	mm/dd/yyyy
☐ Alternative criteria requiring commissioner approval ☐ DEC ☐ PMC ☐ GWPC ☐ SWPC ☐ VolC ☐ GA PMC dilution or dilution and attenuation factor ☐ GB PMC dilution or dilution and attenuation factor	Commissioner approval date(s):	mm/dd/yyyy
☐ LEP-calculated criteria (notice only) ☐ GA PMC (≤ 1,000 mg/kg) ☐ GB PMC (≤ 10,000 mg/kg) ☐ GWPC (≤ 100 x established GWPC & ≤ Res VolC) ☐ SWPC (≤ 100-1,000x WQC based on distance to SW)	No approval required. Calculations and site-specific parameters must be provided in the verification report.
☐ Matrix interference – commissioner approved laboratory reporting limit as clean-up standard ☐ DEC ☐ PMC ☐ GWPC ☐ SWPC ☐ GWVC	Commissioner approval date(s):	mm/dd/yyyy

2. Public Roadways Variance §22a-133k-2(f)(3)
☐ Commissioner granted a public roadways variance ☐ DEC ☐ PMC	Commissioner approval date(s):	mm/dd/yyyy

3. Widespread Polluted Fill Variance (requires EUR) §22a-133k-2(f)(1)
☐ The site is subject to a widespread polluted fill variance.
☐ Commissioner approval	Approval date:	mm/dd/yyyy
☐ LEP certification

4. NAPL Removal Variance (requires ELUR) §22a-133k-2(g)
☐ Commissioner approved variance to the requirement to remove NAPL to the maximum extent prudent.	Approval date(s):	mm/dd/yyyy

5. Engineered Control Variance §22a-133k-2(f)(2)
☐ Engineered controls were constructed at the site.
☐ LEP certified DEC variance	Date of Notification:	mm/dd/yyyy
☐ Commissioner approved EC variance for: ☐ DEC ☐ PMC	Approval date(s):	mm/dd/yyyy
☐ Final engineered control completion statement submitted to the commissioner.	Date submitted:	mm/dd/yyyy
Please complete the EUR (Part IV.C.6) and Financial Assurance (Part IV.C.7) sections.

6. Environmental Use Restrictions (EUR) §22a-133k-1(e)
☐ An EUR was recorded for the site, and the site is currently in compliance with the EUR.	Attach EUR Fact Sheet and Certificate of Title (for an ELUR) or updated title search (for a NAUL) referencing the volume, page, and date the EUR was recorded to this form as Appendix C. If available, attach the Notice of Receipt.
6a. Environmental Land Use Restriction (ELUR)
☐ An ELUR was recorded on the site	Date Certificate of Title accepted by commissioner:	mm/dd/yyyy
6b. Notice of Activity and Use Limitation (NAUL)
☐ A NAUL was recorded on the site
☐ Commissioner Approval	Date final NAUL documents submitted to commissioner:	mm/dd/yyyy
☐ LEP Approval	Date final NAUL documents submitted to commissioner:	mm/dd/yyyy
Date NAUL signed by LEP:	Enter Date

7. Financial Assurance §22a-133k-1(f)
☐ Financial assurance requirements have been evaluated for: ☐ Engineered control variance ☐ Technical impracticability variance
☐ Financial surety established	Date surety instrument information submitted to commissioner:	mm/dd/yyyy
Type of financial surety instrument:	Select Instrument	Attach copy of surety instrument in Appendix B.
☐ Financial surety not required
☐ Amount < $10,000.
☐ Municipality or agency or political subdivision of state or federal government.
☐ Financial surety instrument was established under a previous verification, is still in place, and remains valid.
Comments:	Enter text as needed.

8. Use of Polluted/Treated Soil §22a-133k-2(h)
☐ Soil excavation/use was subject to the following provisions:
8a. Special Waste Release Area IDs
☐ The commissioner authorized the disposal of polluted soil as special waste, as defined in RCRA §22a-209-1.	Enter RA IDs
Approval date(s):	mm/dd/yyyy
8b. On-Site Reuse of Polluted Soil RA where Soil was Reused
☐ Polluted soil was reused on-site.	Enter RA IDs
Date(s) notice provided to the commissioner:	mm/dd/yyyy
Total approx. volume reused:	Enter Volume
Soil exceeds RSR criteria:	☐ Not applicable ☐ DEC ☐ PMC
For soil containing PCBs, date(s) of commissioner approval:	mm/dd/yyyy
8c. Off-Site Reuse of Polluted Soil RA Source(s)
☐ Polluted soil was reused off-site.	Enter RA IDs
Commissioner Approval Date(s):	mm/dd/yyyy
Total approx. volume reused:	Enter Volume

9. In-Situ Remediation
☐ In-Situ remediation was conducted to achieve compliance with applicable criteria.	Release Area ID
☐ Temporary Authorization	Enter RA IDs
Approval date(s):	mm/dd/yyyy
☐ General Permit	Enter RA IDs
Approval date(s):	mm/dd/yyyy

10. Technical Impracticability for Groundwater Remediation §22a-133k-3(e)
☐ The commissioner approved a technical impracticability variance for GWPC and/or SWPC	RA Plume / Site-Wide
Approval date(s):	mm/dd/yyyy	Enter RA IDs
EUR recorded?	☐ Yes ☐ Not applicable
Please complete the EUR (Part IV.C.6) and Financial Assurance (Part IV.C.7) sections, as appropriate.

11. Conditional Exemption for Groundwater Polluted with Pesticides §22a-133k-3(g)(7) & (8)
☐ Compliance with groundwater criteria is not required for pesticides in groundwater resulting from the application of pesticides at the release area.	RA Plume / Site-Wide
☐ Pesticides applied at the parcel are present in groundwater on other parcels at concentrations exceeding the GWPC, and best efforts have been made to ensure that an EUR providing notice has been recorded for the affected parcels.	Attach certification in Appendix B.	Enter RA IDs
☐ Notice of compliance with the requirements of §22a-133k-3(g), including all relevant documents, has been submitted to the Director of Health in the municipality where such pesticides in groundwater are located.	Attach copy of notice in Appendix B.

12. Emerging Technologies & Alternate Approaches for GW Compliance §22a-133k-3(h)(3)(D)
☐ An alternative method of demonstrating compliance with RSR groundwater criteria based on emerging technologies and approaches for which guidance or standard has been published was approved by the commissioner. ☐ Background ☐ GWPC ☐ SWPC ☐ VolC	Release Area ID
Enter RA IDs
Description of alternative method(s): Enter Description
Approval date(s):	mm/dd/yyyy

Part V: Standards for Soil Remediation

A. Soil Release Determination and Investigation
☐ Releases to soil were identified. The verification report documents and explains how the Soil Remediation Standards were achieved at each release area. The nature and distribution of all releases at the subject release area have been characterized in accordance with prevailing standards and guidelines, including the SCGD (Phase III Investigation) or equivalent alternative approach.
1. Identified Releases
Substance Category Criterion Exceeded Prior to Remediation No Exceedance PMC GA GB DEC Res I/C ☐ Non-chlorinated VOCs ☐ □ □ □ □ ☐ Chlorinated VOCs ☐ □ □ □ □ ☐ Metals ☐ □ □ □ □ ☐ PAHs ☐ □ □ □ □ ☐ SVOCs (other than PAHs) ☐ □ □ □ □ ☐ PCBs ☐ □ □ □ □ ☐ Petroleum Hydrocarbons ☐ □ □ □ □ ☐ Pesticides / Herbicides ☐ □ □ □ □ ☐ PFAS ☐ □ □ □ □ ☐ Other Specify ☐ □ □ □ □
2. Compliance Measures Implemented Report Page # / Attachment
☐ None required	Page #
☐ Excavation	Page #
☐ Engineered Control	Page #	Complete Part IV.C.5
☐ EUR	Page #	Complete Part IV.C.6
☐ In-Situ Remediation	Page #
☐ RSR Exemptions	Page #
☐ 95% UCL	Page #
☐ Other Specify	Page #

B. Application of Soil Remediation Standards
1. Background Concentrations in Soil Applicable Release Areas
☐ Compliance is based on background soil conditions instead of the DEC and/or PMC. §22a-133k-2(e)(3) of the RSRs provide prerequisites to demonstrate a background condition exists, and all must apply.	Enter RA IDs

2. Direct Exposure Criteria (DEC)

2a. Compliance with Numeric DEC Applicable Release Areas
☐ Polluted soil meets numeric DEC (check all that apply)
☐ ≤ Residential (Res) DEC	Enter RA IDs
☐ ≤ Industrial/commercial (I/C) DEC (not PCBs) → EUR recorded	Enter RA IDs
☐ Alternative DEC §22a-133k-2(d)(2) → Commissioner-approved ☐ If applicable, an EUR was recorded	Enter RA IDs
☐ PCBs ≤ criteria other than Res DEC
☐ ≤ I/C DEC §22a-133k-2(b)(2)(B) → Non-residential. → Parcel is an electrical substation or other restricted access location. → Use consistent with 40 CFR 761 high-occupancy provisions. → ELUR recorded.	Enter RA IDs
☐ PCBs are inaccessible and ≤ the following:	Enter RA IDs
☐ 10 ppm dry weight (I/C)
☐ 25 ppm dry weight → Other restricted access (40 CFR 761.123)
☐ 25 ppm dry weight → Electrical substation (40 CFR 761.123)
☐ 50 ppm dry weight → Electrical substation and area labeled (40 CFR 761)

§22a-133k-2(e)(1)

2b. Identify Applicable Methods of Demonstrating Compliance with the DEC Applicable Release Areas
☐ All samples from RA ≤ DEC §22a-133k-2(e)(1)	All RAs other than those listed below and in 2c.
☐ 95% UCL of polluted soil in RA ≤ DEC §22a-133k-1(h)(3) → Non-PCBs only	Enter RA IDs
☐ COCs ND at the laboratory reporting limit due to matrix interference → Commissioner-approved	Enter RA IDs

2c. DEC Conditional Exemptions & Variances Applicable Release Areas
☐ DEC exemptions and/or variances were applied at the Site
☐ Inaccessible soil exemption §22a-133k-2(b)(3) → <15 feet deep → EUR recorded	Enter RA IDs
☐ Engineered control variance §22a-133k-2(f)(2) → EUR recorded	Enter RA IDs
☐ Public roadways variance §22a-133k-2(f)(3) → Commissioner-approved	Enter RA IDs
☐ Incidental sources exemption due to: §22a-133k-2(b)(5) ☐ Normal operation of motor vehicles ☐ Normal paving and maintenance of pavement	Enter RA IDs
☐ Pesticide exemption related to: §22a-133k-2(b)(6)	Enter RA IDs
☐ Residential use → Protective measures implemented → EUR recorded
☐ I/C use → Soil management plan in place → EUR prohibiting residential use recorded
☐ Agricultural use → EUR prohibiting residential use recorded

3. Pollutant Mobility Criteria (PMC)

3a. Compliance with Numeric PMC Applicable Release Areas
☐ Polluted soil meets numeric PMC (check all that apply)
☐ Mass analysis ≤ PMC → No inorganics & PCBs	Enter RA IDs
☐ Mass analysis of inorganics or PCBs ÷ 20 ≤ PMC	Enter RA IDs
☐ SPLP/TCLP of inorganics or PCBs ≤ PMC	Enter RA IDs
☐ Alternative PMC ☐ Commissioner-approved ☐ LEP-calculated	Enter RA IDs
☐ Optional PMC (GA or GB) → Complete 3b or 3c

3b. GA Area – Optional Criteria §22a-133k-2(c)(2) Applicable Release Areas
☐ Optional GA criteria were used (check all that apply)
☐ Soil evaluated to seasonal high water table. Remediation to seasonal low water table was technically impracticable or would not result in the permanent elimination of the source.	Enter RA IDs
☐ SPLP/TCLP ≤ GWPC	Enter RA IDs
☐ 10x or alternate dilution (mass or SPLP/TCLP): → Not applicable to ETPH or PCBs → NAPL is not present. → Water table ≥ 15 feet above the bedrock surface. → Downward GW flow velocity ≤ horizontal velocity. → Complete required secondary checklist below criteria selection.	Enter RA IDs
Required secondary checklist for 10x or alternate dilution
One of the following 3 conditions must be selected:
☐ → Public water within 200 feet of subject and adjacent parcels and within 200 feet of any parcel within the areal extent of the RA plume. → GW within plume not used for drinking. → No supply wells within 500 feet of RA. → Affected GW not a potential water supply resource.	Enter RA IDs
☐ → Concentrations of any substance within 75 feet of the nearest downgradient parcel boundary ≤ GWPC. → GW plume is in a diminishing state.	Enter RA IDs
☐ → Concentrations of any substance on the parcel and within 25 feet downgradient of the RA ≤ GWPC. → The subject GW plume is in a diminishing state.	Enter RA IDs

3c. GB Area – Optional Criteria §22a-133k-2(c)(3) Applicable Release Areas
☐ Optional GB criteria were used (check all that apply)
☐ SPLP/TCLP options for RAs with no NAPL present:
☐ ≤ 10x GWPC	Enter RA IDs
☐ ≤ GWPC x ratio of up and downgradient areas (ratio must be ≤ 500)	Enter RA IDs
☐ ≤ GWPC x commissioner-approved alternative dilution or dilution & attenuation factor	Enter RA IDs
☐ Release-specific dilution (mass or SPLP/TCLP): → Does not apply to PCBs. → NAPL is not present above the seasonal high water table. → Water table ≥ 15 feet above the bedrock surface. → Background concentration ≤ GWPC.	Enter RA IDs

3d. Identify Applicable Methods of Demonstrating Compliance with the PMC Applicable Release Areas
☐ All samples from RA ≤ PMC §22a-133k-2(e)(2)	All RAs other than those listed below and in 3e.
☐ 95% UCL of polluted soil in RA ≤ PMC §22a-133k-2(e)(2) §22a-133k-1(h)(3) → Non-PCBs only	Enter RA IDs
☐ COCs ND at the laboratory reporting limit due to matrix interference → Commissioner-approved	Enter RA IDs

3e. PMC Conditional Exemptions & Variances Applicable Release Areas
☐ PMC exemptions and/or variances were applied at the Site (check all that apply)
☐ Environmentally isolated soil exemption §22a-133k-2(c)(5)(A) → EUR recorded	Enter RA IDs
☐ Engineered control variance §22a-133k-2(f)(2) → EUR recorded	Enter RA IDs
☐ Public roadways variance §22a-133k-2(f)(3) → Commissioner-approved	Enter RA IDs
☐ Widespread polluted fill variance §22a-133k-2(f)(1) → Commissioner-approved or LEP-certified	Enter RA IDs
☐ Incidental sources exemption due to: §22a-133k-2(c)(5)(D) ☐ Normal operation of motor vehicles ☐ Normal paving and maintenance of pavement	Enter RA IDs
☐ Polluted material exemption: §22a-133k-2(c)(5)(B) → Exempted PMC exceedances are due solely to coal ash, wood ash, coal fragments, coal slag, coal clinkers, asphalt, or any combination thereof. → VOCs ≤ applicable PMC. → Soil vapor ≤ applicable SVVC or soil is under a building, permanent structure, or engineered control. → Compliance with the DEC has been achieved. → Use of existing groundwater is not affected (including potential public water supply resource or aquifer protection area). → A public water supply distribution system is available within 200 feet of the parcel containing the polluted material and within 200 feet of all adjacent parcels. → The placement of the material was not prohibited by law at the time of placement.	Enter RA IDs
☐ Soil subject to infiltration exemption: §22a-133k-2(c)(5)(C) → 80% (or more) of the mass of the substances remaining at the RA subject to infiltration for at least 5 years. → GW monitoring complies with 22a-133k-3(h)(1) of the RSRs. → Analytical results for all GW sample events collected as specified in 22a-133k-(h)(3) of the RSRs ≤ applicable GW criteria (GWPC, SWPC, and/or water quality criteria).	Enter RA IDs
☐ Pesticide exemption: §22a-133k-2(c)(5)(E) → Pesticides present due solely to application. → Compliance with the DEC has been achieved. → Compliance with GW standards has been achieved.	Enter RA IDs

4. Non-Aqueous Phase Liquids (NAPL) §22a-133k-2(g)
☐ NAPL is/was present at the Site.	Release Area ID
☐ NAPL was removed to the maximum extent practicable.	Enter RA IDs
☐ A variance to removing NAPL to the maximum extent practicable → Commissioner-approved. → ELUR required.	Enter RA IDs

5. Hazardous Waste §22a-133k-2(h)
Release Area ID
☐ Polluted soil meeting the definition of hazardous waste per CGS 22a-449(c) was located on site and was treated, stored, disposed, and/or transported in conformance with RCRA §22a-449(c)-101 through 110.	Enter RA IDs

6. Other Compliance Measures
If applicable, describe other measures taken to achieve compliance with soil remediation standards:
☐ Measures other than those listed above were implemented to achieve compliance with soil standards
Describe Measures:	Enter Text

Part VI: Standards for Groundwater Remediation

A. Groundwater Release Determination and Investigation
1. No Releases to Groundwater
☐ No releases to groundwater were identified. The relevant findings of all “no-release” determinations are presented in the verification report. Groundwater at the subject release area has been investigated in accordance with prevailing standards and guidelines, including the SCGD or equal alternative approach.
☐ Substances were detected in groundwater, but all detected concentrations are representative of naturally occurring background conditions.
Check the following if applicable; otherwise, skip to Part VII:
☐ LEP Calculation of PMC – Groundwater compliance monitoring is in support of LEP calculation and use of alternative release-specific PMC. §22a-133k-2(d)(4)(B)	Skip to Part VI.B.
☐ PMC Exemption for Soil Subject to Infiltration – Groundwater compliance monitoring is in support of soil subject to infiltration to demonstrate compliance with the PMC. §22a-133k-2(c)(5(C)(iii)	Skip to Part VI.B.

2. Releases to Groundwater
☐ Releases to groundwater were identified. The verification report documents and explains how the Groundwater Remediation Standards were achieved at each release area. The seasonal and 3-dimensional distribution of all plumes associated with the subject release area have been characterized in accordance with prevailing standards and guidelines, including the SCGD (Phase III Investigation) or equal alternative approach.
If applicable, complete the following:
☐ An upgradient groundwater plume has impacted the Site. §22a-133k-3(h)(4)
☐ No-comingled plumes – Concentrations of substances in GW at the downgradient parcel may be ≤ concentrations in the GW plume at the boundary between the upgradient and downgradient parcels. → Soil on downgradient parcel complies with the soil standards in 22a-133k-2 of the RSRs. → All exposure pathways associated with drinking water and vapor intrusion have been eliminated or mitigated at the downgradient parcel. → Such substances are not already present in a GW plume at the downgradient parcel.
☐ Comingled plumes – Concentrations of substances in the co-mingled GW plume at the downgradient parcel may be ≤ concentrations in the GW plume at the boundary between the upgradient and downgradient parcels. → Soil on downgradient parcel complies with the soil standards in 22a-133k-2 of the RSRs. → All exposure pathways associated with drinking water and vapor intrusion have been eliminated or mitigated at all parcels impacted by the GW plume emanating from the downgradient parcel.

2a. Identified Releases
Substance Category Above Back-ground1 Criterion Exceeded Prior to Remediation GWPC GA GB2 SWPC VolC Res I/C ☐ Non-chlorinated VOCs ☐ □ □ □ □ □ ☐ Chlorinated VOCs ☐ □ □ □ □ □ ☐ Metals ☐ □ □ □ □ □ ☐ PAHs ☐ □ □ □ □ □ ☐ SVOCs (other than PAHs) ☐ □ □ □ □ □ ☐ PCBs ☐ □ □ □ □ □ ☐ Petroleum Hydrocarbons ☐ □ □ □ □ □ ☐ Pesticides / Herbicides ☐ □ □ □ □ □ ☐ PFAS ☐ □ □ □ □ □ ☐ Other Specify ☐ □ □ □ □ □	1Check the background box if a substance was detected in GW above confirmed background at any time. 2Applicable in GB areas where GW is used as a drinking water supply.
2b. No Compliance Measures Required to Address Releases to Groundwater
☐ Substances, applicable to this verification, were detected in groundwater, but all detected substances in groundwater were less than criteria before remediation or initiation of other compliance measure.	Skip to Part VI.B.
2c. Compliance Measures Implemented Report Page # / Attachment
☐ Air Sparging / Vapor Extraction	Page #
☐ Dual Phase Extraction	Page #
☐ Pump & Treat	Page #
☐ Monitored Natural Attenuation	Page #
☐ Sub-Slab Ventilation	Page #
☐ Vapor Barrier	Page #
☐ EUR	Page #	Complete Part IV.C.6
☐ 95% UCL	Page #
☐ Technical Impracticability	Page #	Complete Part IV.C.10
☐ Emerging Technologies & Alternative Approaches	Page #	Complete Part IV.C.12
☐ Upgradient Groundwater Plume	Page #
☐ RSR Exemptions	Page #
☐ Other Specify	Page #

B. Application of Groundwater Remediation Standards
The following box must be checked for all groundwater monitoring relevant to this verification:
☐ The groundwater monitoring was capable of determining all of the following: §22a-133k-3(h)(1) → Validity of conceptual model for the release area. → Background conditions. → Whether substances were present and ≤ applicable GW criteria. If applicable, check the following: ☐ Remediation was conducted. GW monitoring demonstrated the effectiveness of remediation to eliminate or minimize risks to human health and the environment. ☐ MNA was implemented. GW monitoring demonstrated the effectiveness of MNA to achieve compliance with GW criteria in a reasonable timeframe. ☐ Site in GB area. GW monitoring determined whether a GW plume interferes with existing GW uses. ☐ Upgradient plume(s) present: ☐ Compliance monitoring demonstrated that exposure pathway mitigation was not necessary (complete the applicable portions of this section). ☐ No compliance monitoring necessary because receptor exposure pathways are not present or have been mitigated. If there are no other on-site plumes, skip to Part VII.

1. Prerequisites for Determining Compliance with GW Remediation Standards §22a-133k-3(h)(2&3)
The following prerequisites must be checked if groundwater monitoring was conducted to demonstrate compliance with applicable groundwater criteria. If either box cannot be checked, then verification that groundwater complies with criteria is not appropriate at this time.
☐ All GW compliance samples were collected after: → All remedial actions to achieve compliance with the PMC and applicable GW criteria (if necessary) were completed. → Aquifer no longer subject to transient effects on hydraulic head attributable to remediation or site redevelopment (if conducted). → Any changes to geochemistry have stabilized and equilibrium conditions were established. → GW plume(s) in a diminishing state.
☐ All GW compliance samples were collected over at least 4 sampling events that reflect seasonal variability (except for monitoring conducted in accordance with 22a-133k-3(h)(3)(B)(ii) or (C)(ii)), and monitoring was completed in: ☐ 1 year ☐ 2 years ☐ >2 years for 95% UCL for SWPC (B)(ii) ☐ Heating/cooling seasons for SVVC (C)(ii)
Did a COC exceed criteria during any compliance monitoring event?
☐ Yes ☐ No	If yes, enter page(s) discussed in the verification report:	Page #

2. Background §22a-133k-3(a)(1&2)

§22a-133k-3(h)(3)(A)

2a. Compliance with Background RA Plume / Site-Wide
☐ Groundwater meets background groundwater quality.	Enter RA or Site-Wide
§22a-133k-3(h)(3)(A) Identify Applicable Methods of Demonstrating Compliance with Background
☐ All laboratory results at all sampling locations ≤ background	Enter RA or Site-Wide
☐ 95% UCL of at least 12 consecutive monthly samples ≤ background for each sampling location.	Enter RA or Site-Wide
☐ COCs ND at the laboratory reporting limit due to matrix interference §22a-133k-1(h)(3) → Commissioner-approved	Enter RA or Site-Wide

§22a-133k-3(d) 2b. Remediation to Background in GA Area Not Required RA Plume / Site-Wide
☐ Remediation to GWPC, not background, is applicable.	Enter RA or Site-Wide
Identify at least one condition permitting use of GWPC and complete Part VI.B.3 (GWPC Compliance):
☐ No water supply risk. All of the following apply: → A public water distribution system is available within 200 feet of the subject parcel, all adjacent parcels, and any parcel within the areal extent of the plume. → Plume not located in aquifer protection area. → Plume is not located within the area of influence of any public water supply.	Enter RA or Site-Wide
☐ Prior to any soil or GW remediation, the plume was in a diminishing state.	Enter RA or Site-Wide
☐ Each substance in GW was remediated to the GWPC, and further reduction of concentrations to background cannot be achieved.	Enter RA or Site-Wide
☐ Other exemptions from compliance with background apply (incidental sources, pesticide application).	Complete Part VI.B.5.

3. Groundwater Protection Criteria (GWPC) Compliance RA Plume / Site-Wide
☐ Groundwater complies with GWPC. ☐ GA Area (exempt from background) Complete Part VI.B.2b. ☐ GB Area (GW used for drinking)	Enter RA or Site-Wide
§22a-133k-3(h)(3)(A) Identify Applicable Methods of Demonstrating GWPC Compliance RA Plume / Site-Wide
☐ All laboratory results at all sampling locations ≤ GWPC	Enter RA or Site-Wide
☐ 95% UCL of at least 12 consecutive monthly samples ≤ GWPC for each sampling location. §22a-133k-3(h)(3)(A)	Enter RA or Site-Wide
☐ COCs ND at the laboratory reporting limit due to matrix interference §22a-133k-1(h)(3) → Commissioner-approved	Enter RA or Site-Wide
☐ Exemptions from compliance with the GWPC apply (incidental sources, pesticide application, technical impracticability).	Complete Part VI.B.5.

4. Surface Water Protection Criteria (SWPC) Compliance RA Plume / Site-Wide
☐ Groundwater complies with SWPC
☐ ≤ SWPC §22a-133k-3(a)(1)(B) & -3(a)(2)(A)	Enter RA or Site-Wide
☐ ≤ Appendix D of Water Quality Standards (WQC) §22a-133k-3(a)(3)	Enter RA or Site-Wide
☐ ≤ Background §22a-133k-3(a)(1)(B) & -3(a)(2)(A)	Enter RA or Site-Wide
Identify Applicable Methods of Demonstrating SWPC Compliance RA Plume / Site-Wide
§22a-133k-3(h)(3)(B)(ii) Portion of GW Plume Upgradient of Discharge to SW Body
☐ All laboratory results ≤ SWPC (or WQC or background).	Enter RA or Site-Wide
☐ 95% UCL of at least 12 consecutive monthly samples ≤ SWPC (or WQC or background) for each applicable monitoring location.	Enter RA or Site-Wide
☐ COCs ND at the laboratory reporting limit due to matrix interference §22a-133k-1(h)(3) → Commissioner-approved	Enter RA or Site-Wide
Entire Plume §22a-133k-3(h)(3)(B)(ii)
☐ 95% UCL of entire plume ≤ SWPC (or WQC or background) on a seasonal basis.	Enter RA or Site-Wide
☐ COCs ND at the laboratory reporting limit due to matrix interference §22a-133k-1(h)(3) → Commissioner-approved	Enter RA or Site-Wide
☐ Exemptions from compliance with the SWPC apply (incidental sources, pesticide application, technical impracticability).	Complete Part VI.B.5.

5. Additional Exemptions Applicable to Background, GWPC, and/or SWPC
☐ Exemptions from compliance with background, the GWPC, and/or the SWPC apply: Incidental sources §22a-133k-3(f) Pesticide application §22a-133k-3(g) Technical impracticability §22a-133k-3(e)

5a. Incidental Sources Exemption (Background, GWPC, SWPC) RA Plume / Site-Wide
☐ Incidental sources – exempt from compliance with criteria.
☐ Public drinking water release – Substances resulting from releases of drinking water from a public water supply system.	Enter RA or Site-Wide
☐ Incidental sources of metals, petroleum hydrocarbons, or SVOCs due to: ☐ Normal operation of motor vehicles ☐ Normal paving and maintenance of pavement	Enter RA or Site-Wide

5b. Pesticide Application Exemption (Background, GWPC, SWPC) RA Plume / Site-Wide
☐ Pesticide application – exempt from compliance with criteria. Complete Part IV.C.11 → Local director of health notified → Notice recorded on land records → Impacts due solely to application of pesticides. → Compliance with pesticide soil standards achieved. → Nature and extent of pesticides in GW evaluated. → Potable supply wells on the impacted parcel have been sampled and any exposure pathway to drinking water was eliminated or mitigated. → Well receptor survey completed.	Enter RA or Site-Wide

5c. Technical Impracticability (GWPC, SWPC) RA Plume / Site-Wide
☐ Technical impracticability exemption for GWPC and/or SWPC → Commissioner-approved	Enter RA or Site-Wide

6. Volatilization Criteria (VolC)

6a. Compliance with VolC RA Plume / Site-Wide
☐ Volatile compounds were not detected at the Site
☐ Groundwater complies with VolC
☐ ≤ Residential (Res) VolC	Enter RA or Site-Wide
☐ ≤ Industrial/commercial (I/C) VolC → EUR recorded	Enter RA or Site-Wide
Identify Applicable Methods of Demonstrating VolC Compliance
§22a-133k-3(c)(1)(C) §22a-133k-3(h)(3)(C)(i) ☐ Each substance in groundwater ≤ GW VolC → ≤ 30 feet for volatile substances other than volatile petroleum substances → ≤ 10 feet for volatile petroleum substances	Enter RA or Site-Wide
☐ §22a-133k-1(i) VOCs in groundwater within 15 feet of the ground surface or lowest portion of a building ≤ GW VolC in the table in 22a-133k-1(i)(B) → Prior to 2/16/2021, remediation of VOCs initiated (including public notice) or RAP documenting remediation not necessary submitted to the commissioner → On or before 2/16/2023, remediation of VOCs completed	Enter RA or Site-Wide
☐ Substances exceeding VolC are not at the water table and all analytical results from the uppermost portion of the water column ≤ VolC	§22a-133k-3(c)(2)(B)	Enter RA or Site-Wide
☐ Each substance in soil vapor ≤ soil vapor VolC §22a-133k-3(c)(2)(A) §22a-133k-3(h)(3)(C)(ii) → Heating and cooling seasons represented by data	Enter RA or Site-Wide
☐ COCs ND at the laboratory reporting limit due to matrix interference §22a-133k-1(h)(3) → Commissioner-approved	Enter RA or Site-Wide

6b. Exemptions from Compliance with VolC RA Plume / Site-Wide
☐ Exemptions from compliance with the VolC apply.
Vapor Mitigation Exemption §22a-133k-3(c)(3)
☐ Exemption from VolC for vapor mitigation → Measures to prevent migration of VOCs into overlying buildings have been implemented and demonstrated to be effective. → EUR recorded.	Enter RA or Site-Wide
No-Building Exemption §22a-133k-3(c)(5)
☐ Exemption from VolC for no-building restriction. → No building present over subject GW plume. → For VOCs (other than petroleum VOCs) that exceed applicable VolC within 30 feet of any part of a building, there is no potential vapor intrusion pathway.	Enter RA or Site-Wide
And one of the following conditions must be satisfied:
☐ EUR recorded to prohibit construction of a building.
☐ No building can be constructed. → It has been demonstrated that no building can reasonably be expected to be constructed over the subject groundwater. → Commissioner approved.
☐ Natural attenuation or other methods of remediation will reduce VOC concentrations to applicable VolC within 5 years. → Commissioner approved.
Indoor Air Monitoring Exemption §22a-133k-3(c)(6)
☐ Exemption from VolC through indoor air monitoring. → Commissioner approved monitoring program. → ELUR recorded.	Enter RA or Site-Wide

7. Other Groundwater Compliance Measures Not Documented Above
If applicable, describe other measures taken to achieve compliance with groundwater remediation standards:
☐ Measures not described above were used to achieve compliance with groundwater standards.
Describe Measures:	Enter Text

Part VII: Appendices & Exhibits

Check all that apply and attach appropriate documentation to this Verification Form:
☐ Appendix A – Public Notice Documentation
☐ Appendix B – Approvals and Notifications
☐ Appendix C – EUR Fact Sheet and: Certificate of Title (for ELUR) Updated title search (for NAUL) Notice of Receipt for title documents submitted to the Department (if available)
☐ Exhibit 1 – Map Depicting the Subject Release Area being Verified	Required with all submittals
☐ Exhibit 2 – Verification Report	Required with all submittals