Appendix C "Hazardous Material Release Notification Form" - Rhode Island

What Is Appendix C?

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

Form Details:

  • The latest edition provided by the Rhode Island Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Appendix C by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Environmental Management.

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Download Appendix C "Hazardous Material Release Notification Form" - Rhode Island

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Appendix C
OFFICE OF WASTE MANAGEMENT –
SITE REMEDIATION SECTION
HAZARDOUS MATERIAL RELEASE NOTIFICATION FORM
THIS FORM IS NOT TO BE USED TO REPORT AN IMMINENT HAZARD
1.
Notifier Information
Name:
Address:
Phone:
Email:
Status:
Environmental Professional
Owner
Operator
Secured Creditor
Voluntary
If Environmental Professional is selected, please supply the follow information for your client below:
Name:
Address:
Phone:
Email:
Status:
Owner
Operator
Secured Creditor
Voluntary
2.
Property Information
Name of Site:
Site Address:
Plat/Lot Numbers:
Approximate Acreage of Property:
Latitude/Longitude:
Site Land Usage Type:
Residential
Industrial/Commercial
Location of Release:
(Attach site sketch as necessary)
3.
Release Information
Date of Discovery:
Source:
Release Media:
Hazardous Materials and Concentrations:
(Attach certificates of analysis as necessary)
Extent of Contamination:
Approximate acreage of Contaminated Area:
Appendix C
OFFICE OF WASTE MANAGEMENT –
SITE REMEDIATION SECTION
HAZARDOUS MATERIAL RELEASE NOTIFICATION FORM
THIS FORM IS NOT TO BE USED TO REPORT AN IMMINENT HAZARD
1.
Notifier Information
Name:
Address:
Phone:
Email:
Status:
Environmental Professional
Owner
Operator
Secured Creditor
Voluntary
If Environmental Professional is selected, please supply the follow information for your client below:
Name:
Address:
Phone:
Email:
Status:
Owner
Operator
Secured Creditor
Voluntary
2.
Property Information
Name of Site:
Site Address:
Plat/Lot Numbers:
Approximate Acreage of Property:
Latitude/Longitude:
Site Land Usage Type:
Residential
Industrial/Commercial
Location of Release:
(Attach site sketch as necessary)
3.
Release Information
Date of Discovery:
Source:
Release Media:
Hazardous Materials and Concentrations:
(Attach certificates of analysis as necessary)
Extent of Contamination:
Approximate acreage of Contaminated Area:
4.
Resource Information
Site Land Usage:
Industrial/Commercial
Residential
Adjacent Land Usage:
Industrial/Commercial
Residential
Site Groundwater Class:
GA/GAA
GB
Adjacent Groundwater Class:
GA/GAA
GB
(if different than site groundwater classification within 500 feet)
Nearest Surface Water or Wetland:
Less Than 500 Feet
Greater Than 500 Feet
Potential for adverse impact
Yes/No
5.
Potentially Responsible Parties
Name:
Address:
Status:
Owner
Operator
Other:
Name:
Address:
Status:
Owner
Operator
Other:
6.
Measures Taken or Proposed to be Taken in Response to Release
Check all that apply: __Site Investigation __Short-Term/Emergency __EXPRESS __ Dig & Haul
7.
Other Significant Remarks about Release (Will a background determination be made?)
Signature:
Date
/
/
Title:
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