ECY Form 020-74 "Voluntary Cleanup Program Application Form" - Washington

What Is ECY Form 020-74?

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

Form Details:

  • Released on August 1, 2019;
  • The latest edition provided by the Washington State Department of Ecology;
  • 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 ECY Form 020-74 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download ECY Form 020-74 "Voluntary Cleanup Program Application Form" - Washington

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Voluntary Cleanup Program
Washington State Department of Ecology
Toxics Cleanup Program
APPLICATION FORM
Under the Voluntary Cleanup Program (VCP), the Department of Ecology (Ecology) may provide informal
site-specific technical consultations to persons conducting independent remedial actions at a hazardous
waste site. Ecology may provide such consultations under the authority of the Model Toxics Control Act
(MTCA), Chapter 70.105D RCW, and its implementing regulations, Chapter 173-340 WAC.
To enter the VCP, complete and submit to Ecology a VCP Application. The Application consists of the
following two documents:
 T
1. Application Form (including required attachments).
HIS DOCUMENT
2. Agreement.
For guidance on how to complete your Application, please refer to the Application Instructions, which are
available separately on the VCP web site:
https://ecology.wa.gov/Spills-Cleanup/Contamination-
cleanup/Cleanup-process/Cleanup-options/Voluntary-cleanup-program
Part 1 - ADMINISTRATION
A. Customer Information. The Customer is the person or organization requesting services from
Ecology under the VCP, and is responsible for paying the costs incurred by Ecology. The authority and
duty of the Customer are explained in the Agreement.
Name of Customer:
What type of entity is the Customer?
If the Customer is a “person,” then the Customer shall serve as both
Person
the Project Manager and the Project Billing Contact. Please identify
this person and their contact information in both Parts 1B and 1C.
If the Customer is an “organization,” then please identify the Project
Manager in Part 1B and the Project Billing Contact in Part 1C. Both
Organization
persons must be employed by the Customer organization.
What is the Customer’s involvement at the Site? Please check all that apply.
Property owner
Business owner (operator)
Past property owner
Mortgage holder
Future property owner
Consultant
Property lessee
Attorney
Other – please specify:
If not the current property owner, is the Customer acting as the agent for the property owner?
Yes
No
If not the current property owner, is the Customer authorized to grant access to the property?
Yes
No
1
ECY 020-74 (revised August 2019)
Voluntary Cleanup Program
Washington State Department of Ecology
Toxics Cleanup Program
APPLICATION FORM
Under the Voluntary Cleanup Program (VCP), the Department of Ecology (Ecology) may provide informal
site-specific technical consultations to persons conducting independent remedial actions at a hazardous
waste site. Ecology may provide such consultations under the authority of the Model Toxics Control Act
(MTCA), Chapter 70.105D RCW, and its implementing regulations, Chapter 173-340 WAC.
To enter the VCP, complete and submit to Ecology a VCP Application. The Application consists of the
following two documents:
 T
1. Application Form (including required attachments).
HIS DOCUMENT
2. Agreement.
For guidance on how to complete your Application, please refer to the Application Instructions, which are
available separately on the VCP web site:
https://ecology.wa.gov/Spills-Cleanup/Contamination-
cleanup/Cleanup-process/Cleanup-options/Voluntary-cleanup-program
Part 1 - ADMINISTRATION
A. Customer Information. The Customer is the person or organization requesting services from
Ecology under the VCP, and is responsible for paying the costs incurred by Ecology. The authority and
duty of the Customer are explained in the Agreement.
Name of Customer:
What type of entity is the Customer?
If the Customer is a “person,” then the Customer shall serve as both
Person
the Project Manager and the Project Billing Contact. Please identify
this person and their contact information in both Parts 1B and 1C.
If the Customer is an “organization,” then please identify the Project
Manager in Part 1B and the Project Billing Contact in Part 1C. Both
Organization
persons must be employed by the Customer organization.
What is the Customer’s involvement at the Site? Please check all that apply.
Property owner
Business owner (operator)
Past property owner
Mortgage holder
Future property owner
Consultant
Property lessee
Attorney
Other – please specify:
If not the current property owner, is the Customer acting as the agent for the property owner?
Yes
No
If not the current property owner, is the Customer authorized to grant access to the property?
Yes
No
1
ECY 020-74 (revised August 2019)
Part 1 – ADMINISTRATION continued
B. Project Manager Information. Ecology will send this person all official correspondence. This
person must either be the Customer or be employed by the Customer. This person may not be an
independent contractor hired by the Customer. Please enter the required information below.
Name:
Title:
Mailing address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
C. Project Billing Contact Information. Ecology will send this person monthly invoices. This person
must either be the Customer or be employed by the Customer. This person may not be an independent
contractor hired by the Customer. Please enter the required information below.
Name:
Title:
Mailing address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
D. Project Consultant Information.
Is the Customer a consultant?
Yes
If you answered “YES,” then skip to the next question.
If you answered “NO” and the Customer hired a consultant to conduct the
No
independent remedial action, then enter the required information below.
Name:
Title:
Organization:
Mailing address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Do you want Ecology to contact the Project Consultant?
Yes
No
E. Property Owner Information.
Is the Customer the owner of the property where independent remedial action is being conducted?
Yes
If you answered “YES,” then enter the type of entity and skip to the next question.
No
If you answered “NO,” then please enter all of the required information below.
Name:
Title:
Organization:
Mailing address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Part 1 – ADMINISTRATION continued
2
ECY 020-74 (revised August 2019)
What type of entity is the property owner? Please check only one.
Private
County
Tribal
Municipal
Federal
Mixed
State
Public School
Other – please specify:
F. Request for Written Opinion.
Are you requesting a written opinion at this time?
Yes
No
If you answered “YES,” on what planned or completed remedial action do you want a written opinion?
Please attach to this Application any additional remedial action plans or reports you want
Ecology to review. Ecology will base its opinion on the information contained in the Site file, including
any information attached to this Application.
If you answered “NO,” please explain why you are enrolling in the VCP at this time and when you
expect to request a written opinion from Ecology.
Attach additional pages if necessary.
G. Reporting Requirements.
Please comply with the following reporting requirements when requesting written opinions on planned or
completed remedial actions:
 Licensing. Documents submitted containing geologic, hydrologic, or engineering work must be
under the seal of an appropriately licensed professional, as required by Chapters 18.43 and
18.220 RCW.
 Data Submittal. Environmental sampling data must be submitted in both a printed form and an
electronic form capable of being transferred into Ecology’s data management systems. For
instructions on how to submit the data, please refer to the following Ecology web
site:https://ecology.wa.gov/Research-Data/Data-resources/Environmental-Information-
Management-database/EIM-submit-data
Failure to comply with these requirements may result in
unnecessary delays. Ecology will not issue a No Further Action (NFA) opinion unless
these requirements are satisfied.
3
ECY 020-74 (revised August 2019)
Part 2 - DESCRIPTION OF THE SITE
A. Name of the Site. If Ecology has already identified the Site, enter the name provided by Ecology.
Otherwise, enter a suggested name for the Site. You may also include an alternate name.
Name:
Alternate Name:
B. Location of Property where the Releases Occurred (Source Property).
The “source property” is the property where hazardous substances were released into the environment.
For example, if petroleum was released from a leaking UST, the source property is the property where
the UST was located.
Do you know on which property the releases occurred?
If you answered “YES,” then please refer to the source property when
Yes
answering the following questions.
If you answered “NO,” then please refer to the property addressed by your
No
remedial action (cleanup) when answering the following questions.
Physical Address. Please enter the physical address of the property below.
Street Address:
City:
State:
Zip:
Geographic Position. Please enter the geographical position of the property below. For additional
guidance on how to complete this part, please refer to instructions on the VCP web site.
L
: Degrees:
Minutes:
Seconds:
ATITUDE
C
OORDINATES
L
: Degrees:
Minutes:
Seconds:
ONGITUDE
L
P
:
OCATION ON
ROPERTY
[e.g., point of release or center of parcel]
C
M
:
OLLECTION
ETHOD
[e.g., GPS or address matching]
C
S
:
OLLECTION
OURCE
[i.e., map scale]
H
D
:
ORIZONTAL
ATUM
[i.e., base reference for coordinate system]
A
L
:
CCURACY
EVEL
[i.e., +/- feet or meters]
Legal Descriptions.
TRS D
: Township:
Range:
Section:
Quarter-Quarter:
ATA
T
P
#(
):
AX
ARCEL
S
4
ECY 020-74 (revised August 2019)
Part 2 - DESCRIPTION OF THE SITE continued
C. Identification of Properties affected by the Releases (Affected Properties).
An “affected property” is a property affected by the release of hazardous substances on the source
property. For example, petroleum released from a leaking UST on one property (source property) may
migrate through the soil or ground water onto an adjacent property (affected property).
Do any of the releases affect any properties adjacent to the source property?
If you answered “YES,” then please identify below each property that you
Yes
know has been affected by the releases on the source property. If you
need to identify additional properties, please attach additional pages.
No
If you answered “NO,” then skip to the next question.
Unknown
If you answered “UNKNOWN,” then skip to the next question.
Address:
1.
Tax Parcel(s):
Address:
2.
Tax Parcel(s):
Address:
3.
Tax Parcel(s):
Address:
4.
Tax Parcel(s):
D. Identification of Public Right-of-Ways affected by the Releases.
Do any of the releases affect any public right-of-ways (e.g., streets)?
Yes
No
Unknown
If you answered “YES” above, please specify below. Otherwise, skip to the next question.
Attach additional pages if necessary.
E. Extent of the Site.
What is the approximate areal extent of the Site? Please check only one.
< 5,000 square feet
> 5,000 square feet, but < 1 acre
> 1 acre, but < 10 acres
> 10 acres
Unknown
5
ECY 020-74 (revised August 2019)
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