Form RPD-36 "Norm Site Notification Form" - Louisiana

What Is Form RPD-36?

This is a legal form that was released by the Louisiana Department of Environmental Quality - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2006;
  • The latest edition provided by the Louisiana Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form RPD-36 by clicking the link below or browse more documents and templates provided by the Louisiana Department of Environmental Quality.

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Download Form RPD-36 "Norm Site Notification Form" - Louisiana

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FOR OFFICE USE ONLY
NORM SITE NOTIFICATION FORM
GENERAL LICENSE #
Subject to General Licensure
DEPARTMENT OF ENVIRONMENTAL QUALITY
NORM FACILITY ID#
EMERGENCY & RADIOLOGICAL DIVISION
AI#
LICENSING & REGISTRATIONS SECTION
POST OFFICE BOX 4312
BATON ROUGE, LOUISIANA 70821-4312
PHONE: (225) 219-3041 FAX: (225) 219-3154
Form RPD-36 (Rev 6/06)
This form is for
Site Registration
Site Release
Record Update
NORM NOTIFIER INFORMATION
NORM General License Number:
Agency Interest (AI) Number:
Federal ID#:
LA- __ __ __ __ -N01
Notifier Name:
Physical Address: No. & Street
City & State
Zip Code
Parish
Mailing Address: No. & Street
City & State
Zip Code
Billing Address: No. & Street
City & State
Zip Code
Primary Contact:
Job Title:
Telephone #:
Fax#:
(
)
(
)
NORM SITE INFORMATION
Type of Site (i.e. well site, production facility, pipe yard, drum storage, refinery, etc.):
Facility Name or Well Name:
Well Serial # or Facility ID#:
Field Lease Name (if applicable):
Field ID#:
Physical Location/Address:
Parish:
Location Phone #:
(
)
Directions to Site (origin point from nearest city limits):
Briefly Describe Site (size, terrain, structures):
Describe How This Site Became Subject to Norm Regulations/Type of Contamination:
Section
Township
Range
Latitude
Longitude
________° ________' ________"
________° ________' ________"
FOR OFFICE USE ONLY
NORM SITE NOTIFICATION FORM
GENERAL LICENSE #
Subject to General Licensure
DEPARTMENT OF ENVIRONMENTAL QUALITY
NORM FACILITY ID#
EMERGENCY & RADIOLOGICAL DIVISION
AI#
LICENSING & REGISTRATIONS SECTION
POST OFFICE BOX 4312
BATON ROUGE, LOUISIANA 70821-4312
PHONE: (225) 219-3041 FAX: (225) 219-3154
Form RPD-36 (Rev 6/06)
This form is for
Site Registration
Site Release
Record Update
NORM NOTIFIER INFORMATION
NORM General License Number:
Agency Interest (AI) Number:
Federal ID#:
LA- __ __ __ __ -N01
Notifier Name:
Physical Address: No. & Street
City & State
Zip Code
Parish
Mailing Address: No. & Street
City & State
Zip Code
Billing Address: No. & Street
City & State
Zip Code
Primary Contact:
Job Title:
Telephone #:
Fax#:
(
)
(
)
NORM SITE INFORMATION
Type of Site (i.e. well site, production facility, pipe yard, drum storage, refinery, etc.):
Facility Name or Well Name:
Well Serial # or Facility ID#:
Field Lease Name (if applicable):
Field ID#:
Physical Location/Address:
Parish:
Location Phone #:
(
)
Directions to Site (origin point from nearest city limits):
Briefly Describe Site (size, terrain, structures):
Describe How This Site Became Subject to Norm Regulations/Type of Contamination:
Section
Township
Range
Latitude
Longitude
________° ________' ________"
________° ________' ________"
SURVEY INFORMATION
Survey Date:
BACKGROUND READING
(micro roentgens/hr):
Surveyor’s Name & Company Affiliation:
Radiation Instrument Used:
Calibration Date:
Highest Exposure Reading Measured on a Piece of Equipment (micro
Highest Exposure Reading Measured on the Ground/or Solids
roentgens/hr):
(microroentgens/hr):
Isotope
Activity (picocuries per gram)
TOTAL ACTIVITY
! Radium 226
Concentration:
(picocuries per gram)
! Radium 228
! Other NORM radionuclide(s) _______________
Approved/Accredited Laboratory
Agency Interest Number of Laboratory
ADDITONAL INFORMATION REQUIRED FOR SITE RELEASE REQUESTS
1.
Type of contamination, (i.e., soil, piping, heater treater, etc.)
2.
Location of remediation or decontamination activities
a.
on site – copy(ies) of Form RPD-35 Temporary Jobsite Notification indicating the specific licensee(s) that performed the work
b.
off site – the specific licensee/facility and copy(ies) of Form RPD-37 NORM Waste Manifest indicating transfer
3.
Copy of closeout survey, sample results (pCi/g for soil) performed after cleanup, and qualifications of person who performed survey
4.
Contact person (with phone number) for facility to be released (person to accompany DEQ inspector out to the facility location) Contact person must be
knowledgeable about facility NORM contamination and/or cleanup operations performed at facility
5.
Records indicating the whereabouts and status of NORM waste and/or contaminated equipment transferred from the site including copy(ies) of Form
RPD-37 NORM Waste Manifest to specifically licensed treatment, decontamination, storage, or disposal facilities
6.
Results of tests, experiments, or any other analyses relating to backfill of excavated areas, closure and sealing
7.
Any new information regarding the environmental impact of closure activities and long-term performance of the NORM site
**PLEASE NOTE**
The Department does not consider a Plugged & Abandoned report as confirmation or verification that the previously reported NORM contamination has been removed.
WEB LINKS
Name
Type
Link
RPD-34
REQUEST FOR DISPOSAL IN A WELL TO BE P & A
http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx
RPD-35
TEMPORARY JOBSITE NOTIFICATION
http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx
RPD-36
NOTIFICATION OF A NORM SITE
http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx
RPD-37
NORM WASTE MANIFEST
http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx
DRC-3
NOTICE TO EMPLOYEES-RADIATION NOTICE
http://www.deq.louisiana.gov/portal/tabid/240/Default.aspx
LAC 33:XV
RADIATION PROTECTION REGULATIONS
http://www.deq.louisiana.gov/portal/Default.aspx?tabid=1674
CERTIFICATION
Signature (Responsible Party/Company Representative)
Notification Date
Name (Print)
Job Title
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