Verification Form Instructions

Portion of Property
Release Area
Interim
Form IV Supporting
Site Name
Acreage
LEP/CP Information
Voluntary Program Information
Form III Information
Form IV Supporting Information
Certification
Water Supply Wells
Significant Environmental Hazards
Previous Remedial Program Information
Previous Verification Information
Public Notice
Releases Subsequent to Previous Verification
Soil Table
Groundwater Table
Interim Verifications – Groundwater Section
Required Attachments

*  symbols throughout the form link to specific instructions for that portion of the form. 

*  The address and Rem# in the headers will automatically update upon printing (including printing to PDF or print-previewing). 

* All yellow fields are mandatory.

*  Please let us know if you have any questions or suggestions for improvement of the new forms at DEEP.Verifications@ct.gov.
When opening the new forms through a web browser, Word may generate a security warning that appears at the top of the document.  This is due to the presence of macros that autofill the headers, content controls for the form, and links within the document.


Click the “Enable Content” button for the form to function properly. The Verification Forms (VF) are essentially checklists of all requirements and available provisions in the Remediation Standard Regulations (RSRs).  The VF includes prompts to guide the Licensed Environmental Professional (LEP) through the proper completion of the VF.   All provisions used to achieve compliance with each criterion are to be marked, and appendices are to be attached to the VF as required.

The VF also includes specific references to RSRs provisions. Please review each referenced RSR section prior to completing the VF to ensure that the application of each provision marked as being used to achieve compliance has been properly applied.  Relevant findings that support the applicability and use of the RSRs (as defined in the Verification Report Guidance Document) are to be presented in the Verification Report, which must be attached to the VF.

Certain provisions may be applicable to more than one release area; therefore, the VF includes space to identify the applicable release areas for each provision.  Do not state “all” or “site-wide” in the soil section, as this non-specific entry provides no frame of reference.  If DEEP must conduct a technical review / research to understand the context of the LEP’s application of the RSRs, the Verification will likely be administratively rejected.

Portion of Property forms: To be used when one contiguous portion of the property is being verified.  The portion must be clearly delineated by a class A-2 or similarly accurate survey so that all interested parties can readily identify the location, size, and exact boundary of the portion.  That site survey clearly identifying the portion (see examples below) must be attached to the Verification Form as Exhibit 1.

    

Release area forms:
To be used for one clearly defined area with one single release is being verified. The release area must be clearly delineated by a class A-2 or similarly accurate survey so that all interested parties can readily identify the location, size, and exact boundary of the release area.  That site survey clearly identifying the release area (see examples above) must be attached to the Verification Form as Exhibit 1.

Interim forms: To be used when soil remediation is complete and a long term groundwater remedy is being implemented. The verification must include the estimated duration of the remedy, the operation and maintenance requirements of the remedy, and demonstrate that there are no current exposure pathways caused by groundwater that does not yet meet the remediation standards. Interim Verifications will not close out any previous Rem#’s, but will fulfill the PTP obligation that a verification is filed within 8 years.

Form IV Supporting form:

To be used when natural attenuation or compliance monitoring is not complete or when an EUR is not yet recorded.

Site/Establishment Name and Address:

• If in the Property Transfer Program, use the establishment name and address that were used on the Form filing.
• If identifying a corporation or limited partnership registered with the Secretary of the State, fill in the name exactly as it is shown on that registration.
• If identifying an individual’s property, provide their full legal name.
• Provide the full and exact street address of the location of the site, the Tax Assessor’s location information from the Town land records, and the acreage of the site or establishment.

Acreage

Identify the acreage being verified, which would be the entire site for most verifications, but a smaller acreage for portion of property and release area verifications.

LEP/Certifying Party Information – Complete the contact information for both the LEP and the Certifying Party (CP), including current email addresses and phone numbers.

If any LEP/CP information is missing, the verification will be Administratively Rejected.Voluntary Program Verification Information – Enter the Remediation ID (Rem#) and the date the Environmental Conditions Assessment Form (ECAF) was received by DEEP.  Enter the date of verification, which is the date the LEP signs the verification. Please note: this field will autopopulate the LEP Signature date below.

Property Transfer Form III Filing Information – Enter the Remediation ID (Rem#), the date the Form III was received by DEEP for that filing (this information can be found in the text of the the Form III acknowledgment letter from DEEP), and the date the Phase II Investigation was completed.   Select the effective date the verification: 

• Either the date the Form III was filed or the date the Phase II Investigation was completed, whichever is later.
• A date after the Form III filing and Phase II completion, up to and including the date the verification was signed by the LEP.

If the Final Verification is closing any previous Property Transfer filings, list the applicable Rem#’s in the box on the right.  Note: A Business Verification cannot be used to close a previous Property filing, but a final Property Verification may be used to close a previous Business transfer. Interim Verifications will not close out any previous Rem#’s, but will fulfill the PTP obligation that a verification is filed within 8 years.

Any filings after the effective date of the verification will not be closed with that verification.

Form IV Supporting Verification Information – The applicable date of verification is the date the LEP signs the verification, so that field will autopopulate from the applicable date.

Certification – The LEP is to indicate whether remediation was required or not, provide his/her legal signature and license number, name, date, and imprint or stamp his/her seal in the box provided.

The certification must be signed by a legally authorized and binding representative of the:

• Certifying Party (PTP)
• ECAF Certifying Party (133x)
• Property Owner (133y)
• Eligible Party (BRRP)

Please note: Verification forms lose functionality if filled out on a Mac (radio buttons).

A Note on Indentation:  Questions that are indented refer to the question above it that is not indented.  If the non-indented question is not selected, the indented questions beneath it should be skipped.  For example, in the SEH section, if you indicate no significant hazard was identified, then the indented questions beneath that will not apply to your site and should be skipped.

Water Supply Wells – Indicate the number of drinking water wells in which any level of contamination from an on-site release was detected.

• If filtration is used to supply potable water, indicate the frequency those supply wells are monitored.

Significant Environmental Hazard – Complete this section if applicable. 

• For SEHN filed, Not Applicable is checked when a SEH condition was discovered, but met one of the exceptions to notification, usually surface soil exceeding the SEH threshold that was abated, remediated, or rendered inaccessible prior to the 90 day reporting deadline.  Make sure to list the hazard(s) identified and briefly indicate how it was addressed.

Previous Remedial Program Information – For the Property Transfer Program, only information related to Form III filings is requested because filings under a Form I, II, or IV have already demonstrated that site characterization is complete.

Previous Verification Information – If a previously rendered verification that has been submitted for the subject establishment/site or a Commissioner Approval of Investigation or Remediation is being relied upon by the LEP, provide the requested information.  Then indicate if any of the conditions or environmental controls that may have been used with any such previous verification have changed.

Public Notice – If Public Notice has been completed for this site, complete this section and attach to the verification form copies of:

• notices as published in the newspaper or the newspaper’s certification that it was published,
• copies of the letters sent to the commissioner, local health department, and municipal officials,
• and either
  • letters sent to abutters or
  • dated photos of a sign erected at the site.

Releases to Soil Subsequent to a Previous Verification – Check this box if the releases to soil identified were not addressed by a previous verification.

Identified Releases to Soil Table – For each substance that was detected at concentrations that constituted a release, check the appropriate box along the left side of the table.  If an unlisted substance was detected, check “Other” and indicate the substance detected.  For each substance detected at the site, indicate the criterion exceeded prior to compliance measures indicated in box 2b. or, if no criteria were exceeded, check "No Exceedance.” 

Identified Releases to Groundwater Table –  For each substance that was detected at concentrations that indicated a release, check the appropriate box along the left side of the table.  If an unlisted substance was detected, check “Other” and indicate the substance.  For each substance detected at the site, indicate the criterion exceeded prior to compliance measures indicated in box 2c. or, if no criteria were exceeded, check "Background.” Note: this background box is not related to compliance.  Whether or not compliance with background is applicable is addressed in Part VI.B.3.

Interim Verifications – Groundwater Section

• Complete Part VI: Groundwater Remedy in Operation for anywhere groundwater remediation/monitoring is in progress.
• Complete Part VII: Standards for Groundwater Remediation for any plumes for which remediation is complete. If there were no other plumes on this site, leave this section blank
  

Required Attachments to the Verification Form

Approvals and Notifications

• A copy of the Commissioner’s APS approval
• A copy of the Commissioner’s AC approval
• Notice of LEP-calculated criteria
• The 95% UCL calculations and input data
• A copy of the Commissioner’s Engineered Control approval
• A copy of the Financial Surety Mechanism for the Engineered Control
• A copy of the EUR Fact Sheet and EUR Certificate of Title
• A copy of the Commissioner’s approval of variance(s)
• A copy of the General Permit or Temporary Authorization for In Situ Remediation 
• A copy of the Commissioner’s approval for off-site use of polluted soil
  

A copy of the Public Notice and discussion of any public comments received

An A2 survey clearly delineating the Portion of the property or Release Area being verified

If you have questions about the verification form that are not answered above, please email your question(s) to DEEP.Verifications@ct.gov.

LEP Verifications

Content last updated September 12, 2023