FINAL Engineered Control Completion STATEMENT

DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION

BUREAU OF WATER PROTECTION AND LAND REUSE

REMEDIATION DIVISION	www.ct.gov/deep/remediation

79 Elm St., Hartford, CT 06106-5127

Please use this form to submit the Final Engineered Control Completion Statement in accordance with the Remediation Standard Regulations (RSRs), §22a-133k-2(f)(2)(D) of the Regulations of Connecticut State Agencies. The EC Completion Statement must be submitted electronically by uploading the document to the Connecticut Secure File Transfer (SFT) website using the Electronic Document Transmittal Form (embedded as the first page of the electronic document). The EC Completion Statement must be submitted within 120 days from completion of construction of the engineered control. The address and Rem# in the headers will automatically update upon printing (including printing to pdf) or print-previewing. Yellow fields are mandatory.

Part I: Site Information

Site Name (current or former name) Establishment Name	REM IDs: Rem # Rem # Rem #
Site Street Address Establishment Address
City/ Town City/Town	State CT	ZIP 00000

Responsible Party	Property Owner, if different from Responsible Party
Name Name	Name Name
Company Company Name	Company Company Name
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: Engineered Control Conceptual Site Model

Constituents of Concern within the Engineered Control Area
COC Category Criterion Exceeded at EC Release Area ID PMC GA GB DEC Res I/C ☐ Non-chlorinated VOCs □ □ □ □ Enter RA IDs ☐ Chlorinated VOCs □ □ □ □ Enter RA IDs ☐ Metals □ □ □ □ Enter RA IDs ☐ PAHs □ □ □ □ Enter RA IDs ☐ SVOCs (other than PAHs) □ □ □ □ Enter RA IDs ☐ PCBs □ □ □ □ Enter RA IDs ☐ Petroleum Hydrocarbons □ □ □ □ Enter RA IDs ☐ Pesticides / Herbicides □ □ □ □ Enter RA IDs ☐ Other [Specify] □ □ □ □ Enter RA IDs ☐ Other [Specify] □ □ □ □ Enter RA IDs

Part III: Engineered Control Design

☐ LEP certified EC variance Commissioner Approval of EC ☐ DEC ☐ PMC Approval Date(s): mm/dd/yyyy Attach a copy of the approval to this form ☐ Public Notice of remediation posted in accordance with the requirements of §22a-134a and §22a-133k-1(d). Public Notice Dates(s): mm/dd/yyyy Attach a copy of the public notice to this form EC Construction Complete Date of Completion: mm/dd/yyyy Attach representative photographs of EC taken within 120 days of submittal of this EC Completion Statement

LEP Certification of an Engineered Control Variance
☐ The LEP certifies that the eligibility requirements §22a-133k-2(f)(2)(A) and the requirements of §22a-133k-2(f)(2)(B) have been satisfied.
Please select applicable EC Design
Final Cover Material EC specifications Demarcation Layer Release Area ID Yes No, Exempt ☐ Shallow rooted vegetation, mulch, or gravel §22a-133k-2(f)(2)(B)(i)(I) Minimum of one (1) foot of material □ □ pre-existing mature lawn for minimum 3 years Enter RA IDs ☐ Shrubbery §22a-133k-2(f)(2)(B)(i)(II) Minimum of eighteen (18) inches of material1 □ □ pre-existing mature shrubbery Enter RA IDs ☐ Trees §22a-133k-2(f)(2)(B)(i)(III) Minimum eighteen (18) inches material1 measured vertically from the ground surface and extending horizontally to a radius equivalent to the full extent of the tree crown when mature □ □ pre-existing Enter RA IDs ☐ Non-paved hardscape §22a-133k-2(f)(2)(B)(i)(IV) Minimum of nine (9) inches of a combined thickness of hardscape and sub-base □ □ pre-existing hardscape Enter RA IDs ☐ Paved2 §22a-133k-2(f)(2)(B)(i)(V) Minimum of two and one-half (2.5) inches of bituminous concrete with a minimum of six (6) inches of sub-base or a minimum of four (4) inches of reinforced concrete □ □ area greater than five (5) feet wide or greater than 500 square feet □ pre-existing paved surface Enter RA IDs ☐ Ground-mounted solar array anchored by a concrete ballast §22a-133k-2(f)(2)(B)(i)(VI) concrete ballast for the solar array shall be underlain with a minimum of one (1) foot of material1 and all remaining infrastructure associated with the solar array installation shall consist of a minimum of two (2) feet of material1 □ No exemptions Enter RA IDs

Commissioner Approved Engineered Control
Engineered Control Design Brief description of constructed EC(s) and identify any minor deviations from the approved application: Use additional sheets, if necessary
Click here to enter text.

Part IV: Actions Required for Maintaining an Engineered Control Variance

Professional Engineer (PE) Signed and Sealed As-Built Drawings
☐ PE signed and sealed as-built drawings Attach copy of drawings to this form

LEP Certification of EC Completion Statement
LEP Certification: “I hereby certify that the Engineered Control complies with the requirements of §22a-133k-2(f)(2).”
LEP Printed/Typed Name Name	LEP Address Address
LEP Company Company Name	City/Town City/Town	State State	Zip 00000
LEP Signature	Phone Phone
Date of Signature mm/dd/yyyy	License # Number	E-mail E-mail

Financial Assurance Attach copy of detailed cost estimate for anticipated operation, monitoring, and maintenance costs for the EC.
Check all that apply
☐ Financial assurance established	Date financial assurance submitted to commissioner:	mm/dd/yyyy
Type of financial assurance:	Select Mechanism	Attach copy of financial assurance to this form.
☐ Financial assurance not required
☐ Amount < $10,000
☐ Municipality or agency or political subdivision of state or federal government
☐ Previous ECs installed at the Site
☐ Financial assurance established	Amount:	$00,000
☐ Amount < $10,000
Total amount of financial assurance for current and previous ECs installed at the Parcel:	$00,000	FA may be required if total FA for multiple ECs is > $10,000

Environmental Use Restrictions (EUR)
Check all that apply
☐ An EUR was recorded for the site, and the site is currently in compliance with the EUR	Date EUR recorded	mm/dd/yyyy
☐ Property Owner acknowledges and consents to EC and EUR	Attach Property Owner’s consent to this form
☐ A request for EUR will be submitted within 180 days of completion of EC	Date EUR to be submitted to the commissioner	mm/dd/yyyy
☐ An NAUL can be used, or the site is being remediated pursuant to section 22a-133y of the Connecticut General Statutes, and an EUR will be approved by LEP within 180 days of completion of EC	Date EUR to be approved by LEP	mm/dd/yyyy
☐ A request for extension to record EUR was submitted to the commissioner	Date request submitted to commissioner	mm/dd/yyyy

Part V: Attachments

Check all that apply and attach appropriate documentation to this Form
☐ Commissioner Approval of EC
☐ Public Notice Documentation
☐ Plans and Specifications for LEP Certification of an EC Variance
☐ Representative Photographs of the EC Taken within 120 days of Submittal of This EC Completion Statement
☐ PE Signed and Sealed As-Built Drawings
☐ Financial Assurance Documentation
☐ Property Owner’s Acknowledgement and Consent to EC and EUR

Concentrations of any substances in material must be equal to or less than the applicable direct exposure criteria

Pursuant to §22a-133k-2(f)(2)(B)(i)(IV) and (V), a professional engineer shall sign and seal a plan and specifications indicating that the EC meets the requirements of the applicable provision. Attach a copy of the plan and specifications to this form