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

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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;
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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.

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

Type of contamination, (i.e., soil, piping, heater treater, etc.)

Location of remediation or decontamination activities

on site – copy(ies) of Form RPD-35 Temporary Jobsite Notification indicating the specific licensee(s) that performed the work

off site – the specific licensee/facility and copy(ies) of Form RPD-37 NORM Waste Manifest indicating transfer

Copy of closeout survey, sample results (pCi/g for soil) performed after cleanup, and qualifications of person who performed survey

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

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

Results of tests, experiments, or any other analyses relating to backfill of excavated areas, closure and sealing

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