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Consultant Information

Name*

Address

City

State

Zip

Phone*

Fax

E-mail*

Contact

Project Information

Project Name

Project Location/Postal Address

Prior Remedial Activities

Site
Occupied/ActiveVacant/Inactive

Paved
YesNo

Water
YesNo

Electricity
YesNo

Necessary Information to Accurately Evaluate Site

Please submit a copy of the Site Characterization Report, Site Remediation Report and/or Periodic Monitoring Report. Please include a scaled site map, groundwater contour map, & groundwater and/or soil plume map, soil boring and monitoring well logs from within the treatment area, and historical analytical tables (contaminant concentrations, TPH, TOC, DOC, and Heterotrophic Plate Counts) for soil and groundwater contamination.

Contaminant Information

Contaminant(s)

Product(s) Released and Source

Remediation Goals

Contaminated Media
SoilSmear ZoneGroundwater

NAPL Present
YesNo

Off-Site Contamination
YesNo

Subsurface Parameters

Soil Types

Unsaturated Zone (ft.)

Depth to GW (ft.)

Areal Extent of Contamination (length in feet)

Width (in feet)

Vertical Extent of Contamination (ft.)

To depth of (ft.)

Volume to be Treated (cubic yards)

Additional Information

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