ADEM Form 521 "Application to Participate - Voluntary Cleanup Program" - Alabama

What Is ADEM Form 521?

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

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • 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 ADEM Form 521 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 521 "Application to Participate - Voluntary Cleanup Program" - Alabama

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Alabama Department of Environmental Management
Voluntary Cleanup Program
Application to Participate
Any person desiring to participate in the voluntary cleanup program shall submit a
completed application and appropriate fees. Applications may be submitted individually or
in conjunction with assessment or cleanup plans and reports. Each application shall, as a
minimum, include:
A.
APPLICANT INFORMATION
Name:
Mailing Address:
Telephone Number:
(
)
Fax:
(
)
Email Address: _____________________________________________________________________
Owner or Responsible Corporate Official:
Name:
Title:
Is the Applicant a Responsible Party as defined in ADEM Admin. Code 335-15-1-.02(vv)?
Yes
No
B.
SITE INFORMATION
Name of Site:
Physical Address:
Site Owner(s) Name:
Mailing Address:
Telephone Number: (
)
Fax: (
)
ADEM Form 521 05/20 m1
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Alabama Department of Environmental Management
Voluntary Cleanup Program
Application to Participate
Any person desiring to participate in the voluntary cleanup program shall submit a
completed application and appropriate fees. Applications may be submitted individually or
in conjunction with assessment or cleanup plans and reports. Each application shall, as a
minimum, include:
A.
APPLICANT INFORMATION
Name:
Mailing Address:
Telephone Number:
(
)
Fax:
(
)
Email Address: _____________________________________________________________________
Owner or Responsible Corporate Official:
Name:
Title:
Is the Applicant a Responsible Party as defined in ADEM Admin. Code 335-15-1-.02(vv)?
Yes
No
B.
SITE INFORMATION
Name of Site:
Physical Address:
Site Owner(s) Name:
Mailing Address:
Telephone Number: (
)
Fax: (
)
ADEM Form 521 05/20 m1
1
Location of Site:
Latitude:
Longitude:
Area of the Site:
acres
County:
Estimated Population within One Mile Radius of the Site:
Estimation Method:
C.
SITE HISTORY
Provide a narrative description, including time frames, of the current and past usage
of the property, to the extent known or reasonably ascertainable. Include the date of
purchase by the current owner of the site.
D.
CURRENT PROPERTY FEATURES
Provide the results of a recent property inspection. Discuss man-made structures,
areas of suspected contamination, surface water features and other pertinent site
features. Include the name of the person conducting the inspection, their title and
business affiliation, and date of the inspection.
E.
MAPS
Include one or more legible property maps indicating the locations of all units,
structures, features, and potential sources of contamination. The maps shall be to
scale and show:
1.
Location of all water bodies, ponds, springs, rivers and streams
(including subterranean), estuaries, and wetlands;
2.
Boundary lines of the Site;
3.
Current land use of contiguous properties;
4.
Engineered structures such as drainage ways, diversion ditches, drain
tiles, manholes, water lines, and sewers;
5.
Highways, roads, roadcuts, paved areas, and railroad lines;
6.
Geologic features such as outcrops, faults, caves, and sinkholes; and
7.
Any other distinguishing structures discovered during the inspection.
8.
All maps must include an appropriate scale, a north arrow; and a legend.
Also include a United States Geological Survey 7.5 minute quadrangle map with the
site delineated.
Form 521 05/20 m1
F.
COMPLIANCE WITH PERMITS, STATUTES OR REGULATIONS
Include a list of all orders, citations, and notices of violation issued to the applicant for
any violations or alleged violations of environmental permits, laws and/or regulations.
The applicant shall include a brief description of the violation(s) and the terms and
status of any required remedial action(s) associated with the violations.
If there are no orders, citations, and notices of violation issued to the applicant for any
violations or alleged violations of environmental permits, laws and/or regulations,
check below. No further information is required.
There are no orders, citations, and notices of violation issued to the applicant.
G.
PROPERTY ELIGIBILITY CRITERIA.
To be considered a qualifying property for participation in the voluntary cleanup
program, a property shall, unless granted a variance as under ADEM Administrative
Code 335-15-2-.03, meet the following criteria:
1.
It must not be listed on the National Priorities List pursuant to CERCLA;
2.
It must not be currently undergoing response activities required by an
order of ADEM;
3.
It must not be currently undergoing response activities required by an
order of EPA issued pursuant to CERCLA;
4.
It must not be a hazardous waste treatment, storage, or disposal facility
subject to the permitting requirements of 335-14-8-.01 through 335-14-
8-.08.
Is this Site eligible for participation in the voluntary cleanup program?
Yes
No
If the answer is No, is the applicant including a request for a variance pursuant to 335-
15-2-.03?
Yes
No
H.
OTHER INFORMATION
The Applicant may include any additional information it considers pertinent to the Site
that the Applicant wishes ADEM to consider when reviewing the application. ADEM
reserves the right to request any additional information it deems necessary for
consideration of the application.
ADEM Form 521 05/20 m1
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I.
FEES
The Applicant should contact the Environmental Services Branch for details of the
applicable fees to be submitted. A fee schedule may be found in ADEM Admin. Code
335-1-6 Fee Schedule H.
J.
CERTIFICATION
The Owner or Responsible Corporate official shall sign the application and certify as to
the accuracy of the information submitted with the application.
“I certify under penalty of law that this document and all attachments were prepared
under my direction or supervision in accordance with a system designed to assure that
qualified personnel properly gather and evaluate the information submitted. Based on
my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true, accurate, and complete. I am aware that there are
significant penalties for submitting false information, including the possible revocation of
the limitations of liability and removal from the program.”
Responsible Corporate Official of Applicant:
Title:
(signature)
Date:
(please print or type name)
ADEM Form 521 05/20 m1
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Instructions for ADEM Form 521
To participate in the Voluntary Cleanup Program pursuant to ADEM Administrative
Code 335-15, an Applicant must complete ADEM Form 521 as instructed below.
For each Section, complete the Form as follows:
A.
Applicant Information.
Provide the name and address of the person, company or organization applying to
participate in the VCP. This is information for the applicant only. Provide the name of
the Responsible Corporate Official if the applicant is not an individual or individuals.
A Responsible Corporate Official is an officer of the company with the title of President,
Vice President, Chief Operating Officer, a Mayor of a municipality, or a Chairman of a
County Commission.
Indicate if the Applicant is a Responsible Party as defined in ADEM Admin. Code 335-
15-1-.02(vv)?
B.
Site Information.
Provide the name of the site (as described by the applicant) and the physical address
of the site. Provide the name and mailing address of the property owner if different
from the applicant. Provide information on the location of the site. Latitude and
Longitude shall be reported in decimal format. Estimate total population within a one
mile radius of the site entrance to the extent reasonably ascertainable, and provide a
brief description of the method used to estimate population.
C.
Site History.
Follow the instructions as provided.
D.
Current Property Features.
Follow the instructions as provided.
E.
Maps.
Follow the instructions as provided.
F.
Compliance with Permits, Statutes or Regulations
Follow the instructions as provided. Check in the designated location if there are no
orders, citations, and notices of violation issued to the applicant.
G.
Property Eligibility Criteria
Review the eligibility requirements found in ADEM Admin. Code 335-15-2 and check
in the designated location if the site is eligible and, if not, is a variance request being
submitted.
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