SCOPE OF WORK INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

State Form 51955 (R / 12-08) OFFICE OF LAND QUALITY

Pursuant to 328 IAC 1-3-3(a)(1) EXCESS LIABILITY TRUST FUND
Telephone: (317) 234-0990
Fax number: (317) 234-0428

INSTRUCTIONS: 1. This form must be included for all proposed corrective actions submitted after September 29, 2004, [328 IAC 1-3-3(a)(1)] and should be
included with technical documents related to the below referenced phases.

2. Detail each proposed activity on a separate line and provide a detailed description of each in the appropriate field.

3. Table 1 is to provide a detailed breakdown of proposed work activities utilizing the Activity Code Classification Key below. Table 2 and
Table 3 are to provide detailed technical specifications for proposed wells and borings along with detailed specifications of proposed
pilot studies and/or remedial systems.

NOTE: This form does not constitute pre-approval of corrective action related costs, as provided for in 328 IAC 1-3-1.6.

SUBMIT Indiana Department of Environmental Management

Facility ID Number:      
COMPLETED Attention: ELTF Section
FORM TO: 100 North Senate Avenue Incident Number:      
Indianapolis, IN 46204-2251

RP Name:       Site Name:      

RP
Address:       Site Address:      
           
           
      Consultant:      
RP Phone: (     )       Consultant Phone: (     )      
Contact Name:      
[RP = Responsible Party]

Phase Categorization
Check only one Phase below:
Site Characterization / FSI Pre-CAP Approval Monitoring CAP Implementation
FSI / CAP Development CAP Addendum Site Closure

Activity Code Classification Key

Please use the codes listed below when filling in the form:

A. Office Activities / Report

C. Site Activities
Generation
Labor A010 Labor C010 Supplies C080
Supplies & Materials A020 Equipment Rental C020 Other C090
Subcontractor - Site Investigation Specifications
B. Analytical
Labor C031 (see TABLE 2)
Ground Water B010 Materials C032 Remediation Technical Specifications
Subsurface Soil B020 Other C033 (see TABLE 3)
Surface Water B030 Disposal C040
Surface Soil B040 Permits C050
Air B050 Site Prep / Demolition C060
Other B060 Site Restoration C070

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 LUST Incident number:      

TABLE 1
Proposed Scope of Work Details
IDEM
Proposed Activity Adjusted
Units Unit Type Activity and Detailed Description Units
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            

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 LUST Incident number:      

TABLE 1 – continued –
Proposed Scope of Work Details
IDEM
Proposed Adjusted
Units Unit Type Code Activity and Detailed Description Units
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            

TABLE 2
Proposed Well and Soil Boring Specifications
Type Depth
Boring / Well R
[monitoring a
or extraction] n
g
e Total IDEM
Number Adjusted
Proposed (feet) (feet) Details Units
                                   
                                   
                                   
                                   
                                   
                                   
                                   

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Proposed Remediation Technical Specifications
I. Proposed Pilot Study Specifications
Type: MNA ORCs Pump & Treat
[see below] Other:      
Equipment: Direct Push Equipment
Submersible Pump
Other:
II. Proposed Remedial System Specifications [check / fill out all that apply]
Monitored Natural Attenuation (MNA)
Sampling for MNA Parameters:
Number of Monitoring Wells:
Oxygen Releasing Compounds (ORCs)
Number of Injection Points:
Total Pounds of ORCs:   
Number of Injection Events:
Pump and Treat
Number of Recovery Wells:
Number of Submersible Pumps:
Number of Air Strippers:
Number of Carbon Vessels (GAC):
Number of Transfer Pumps:
Capacity of Knockout Tank (gallons):   
Number of Bag/Sediment Filters:
Soil Vapor Extraction / Air Sparge (SVE / AS)
Number of SVE Points:   
Number of AS Points:   
Number of Blowers/Vacuum Pumps:   
Number of Air Compressors:   
Capacity of Knockout Tack (gallons):   
Radius of Influence (ROI) in Feet:   
LUST Incident number:      
TABLE 3
SVE / AS VER EFR DPE/ MPE
Vacuum Truck Vacuum Pump / Blower Liquid Ring Pump
Air Compressor Other:      
Other:       Other:      
Vacuum Enhanced Recovery (VER)
Yes No Number of SVE/Recovery Wells:     
    Number of Submersible Pumps:     
Number of Blowers/Vacuum Pumps:     
Number of Air Strippers:     
    Number of Carbon Vessels (GAC):     
    Number of Transfer Pumps:     
    Capacity of Knockout Tank (gallons):     
Number of Bag/Sediment Filters:     
    Enhanced Fluid Recovery (EFR)
    LPH Present in Extraction Wells? Yes No
    Number of Extraction Points:     
    Number of Approved Events:     
   
    Dual or Multi Phase Recovery (DPE / MPE)
    Number of Extraction Points:     
Number of Liquid Ring Pumps (LRPs):     
Number of Air Strippers:     
   Number of Carbon Vessels (GAC):     
   Number of Transfer Pumps:     
   Capacity of Knockout Tank (gallons):     
   Number of Bag/Sediment Filters:     
   Excavation / Trenching
   Number of Cubic Yards:      
Number of Tons (yds3 * 1.36):      
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 Other:       Depth of Excavation:       feet
      Linear Footage of Trenching:       feet

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