Fillable Printable Form 53413
Fillable Printable Form 53413
Form 53413
Page 1 of 6
INSTRUCTIONS: This checklist shall be completed and returned for all Remediation Work Plan (RWP) submittals required under IC 13-25-5-7.
When completed, please return this form and support documents to the address given in the box above.
The RWP provides the basis for IDEM to evaluate the proposed remedy for each VRP site. All of the following
information is required to evaluate the selected remedy’s effectiveness and to demonstrate that it is the most
effective remedy for the site. The remediation work plan must provide a complete description of the past
operations, the site investigation and the selected remedy for the site.
Required Elements Present Location
Site Delineated (Required for Approval)
If “No” Explain
2 Paper Copies and 1 Electronic Copy of RWP (Large QA/QC
data packets can be submitted as 1 electronic copy)
REQUIRED
I. INTRODUCTION
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. Sources of contamination
1. Site name, address, and telephone
2. Current owner and contact information
3. Historical summary of site ownership
4. Type of facility, past and present operations
5. Site contact responsible for VRP process
6. Overview of initial discovery of contamination, spill
history, & previous investigations conducted at the site
B. Supporting Documents
1. Discussion of relevant previous reports
2. Data and documentation regarding site
C. Remedial Action Objectives
1. Remediation and cleanup objectives for all affected
source areas, media, contaminants, and exposure
pathways
2. Work items planned for remediation
II. INVESTIGATION ACTIVITIES
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. Summary of Information Used to Select Remedy
1. Baseline assessment and literature search
a. Geologic and hydrogeologic summary
b. Physical and political geographic information
2. Extent of subsurface work, including:
a. Copies of all boring logs and monitoring well
construction logs
b. Boring and well location maps
c. Field screening results for soils and groundwater
d. Sample location map, cross sections, groundwater
flow, and isoconcentrations maps
REMEDIATION WORK PLAN
COMPLETENESS CHECKLIST
State Form 53413 (R / 2-13)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
OFFICE OF LAND QUALITY
VOLUNTARY REMEDIATION SECTION
100 N. Senate Avenue
Indianapolis, IN 46204-2251
Reset Form
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Report/Plan Element Present
(Y,N, or NA)
Location in Document
B. Summary of Site Investigation
1. Identification of all contaminants
a. Chemical and physical properties
b. Contaminant toxicological data
c. Potential effects of residual contamination
2. Summary of site-specific Geology & Hydrogeology
3. Discussion of Sources of Contamination
4. Summary and Map of Extent of Contamination
a. Impacted media, such as soil, soil vapor, sediment,
groundwater, surface water, and air
b. Concentrations of contaminants with tables
c. Concentration trends
C. Summary of Risks Associated with Site
1. Human, ecological, and environmental risks for each
contaminant & impacted media, including discussion
of long and short-term risks, environmentally sensitive
areas, and endangered species
2. Impact of current and future land-use issues, if
applicable, including need for environmental deed
restrictions and restrictive ordinances
D. Background Concentration Assessment
1. Summary of naturally occurring site contaminants
2. Background data in tabular format & background
sampling location map
3. Statistical comparison of background concentrations to
concentrations in potentially contaminated media
4. Reliability and applicability of background data
E. Additional Field Investigation Requirements
1. Additional investigations required to effectively
complete the design or the installation of the selected
remedial method
2. Reasons for additional investigation
3. Description of additional work to be completed
VAPOR INTRUSION
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. Discussion of ground water results compared with the
Tables in the IDEM Remediation Closure Guide
B. Description of further monitoring required until detected
levels are below the screening levels in the Remediation
Closure Guide
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III. REMEDIATION PLAN
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. Evaluation of Remedial Alternatives
1. The remedial alternatives evaluated must be identified,
and the rationale for their selection must be provided.
In addition, the remediation work plan should describe
parameters evaluated for each of the selected
alternatives. The parameters should include, but not
necessarily be limited to, the following:
a. Extent of remediation effort
b. Technical feasibility to address physical and
chemical characteristics of media
c. Projected contamination removal & treatment rates
d. Protectiveness of human health
e. Cleanup criteria
f. Ability of each alternative to achieve cleanup criteria
g. Community acceptance
h. Anticipated volume of contaminated materials to be
treated
i. Ease of technology application or implementation
j. Dimensions of major technologies & space
limitations
k. Process parameters
l. Clean up time frames
m.Transportation distances
n. O&M Costs
o. Any other special considerations
2. Summarize conclusions for each of the technologies
evaluated, and provide reasons each technology would
or would not be appropriate
3. Need for treatability study or pilot test. Describe the
treatability study or pilot test and the reasons it is
required, and provide the following information:
a. Proposed study methodology
b. Clear statement of treatability study or waste
characterization objectives
c. Proposed scale of study (e.g., bench, pilot, etc.)
d. Data requirements and evaluation
e. Pilot plan startup and O&M
f. Schedule for pilot study
g. Remedial technologies to be tested & equipment
required
h. Treatability assessment and waste characterization
i. Proposed disposal arrangements for wastes caused
during remediation, plus approvals & necessary
documentation
j. Installation and startup procedures, including:
- Data requirements and analytical methods
- Pilot Plan O&M requirements
- Data analysis & interpretation of results to be used
- Full-scale technology application requirements and
notation of limitations & optimum operating
conditions
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Report/Plan Element Present
(Y,N, or NA)
Location in Document
B. Selected Remediation Technology – If more than one
remedial alternative will be used to address different on-
site areas, the remediation work plan must describe how
the remediation system, as a whole, will work. A flow
diagram, conceptual sketch, or other approach should be
used to illustrate the components of the remediation
system. Major equipment, such as pumps, air strippers,
and in-situ treatment equipment, must be indicated. The
work plan should include a site map showing areas to be
remediated and proposed locations of major equipment.
1. Identify which evaluated technology or combination of
technologies will be implemented at the site, including
the technical, economic and social acceptance
rationales for the final selection.
2. Identify the need for risk assessment and provide:
a. Parameters to be addressed
b. Proposed risk assessment methodologies
c. Potential exposure pathways
d. Exposure assumptions
e. Environmental fate and transport data
f. Tabulated parameters and resulting cleanup levels
3. Provide a detailed description of the selected
technology and system setup, including the following
information:
a. Technical specifications of all equipment &
processes
b. Proposed locations of all remediation equipment on
a scaled site map, including piping runs and
electrical wiring where applicable
c. State or federal permit requirements for the system
d. Waste disposal approvals needed to implement
system
C. Monitoring and Sampling Plan
1. Sampling plan details, including:
a. Sampling and monitoring parameters
b. Sampling and monitoring frequency
c. Schedule for submitting results to IDEM for review
and evaluation (quarterly progress reporting is
minimum requirement)
Provide data management details, including a
discussion of how the monitoring & confirmation
sampling data will be documented & reported, &
proposed progress reports formatting
D. Project Work Schedule
1. Projected installation and startup
2. Sampling and monitoring schedule
3. Contaminant removal & treatment rates, including
remediation progress milestones & projected
completion dates
4. O&M Plan, including:
a. Optimal operating conditions
b. Necessary O&M tasks, their frequency, replacement
schedule & planned O&M replacement events
c. Proposed inspection schedule
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Report/Plan Element Present
(Y,N, or NA)
Location in Document
d. Potential problems and their remedies
e. Contingency plan indicating how the applicant plans
to respond in the event of a system failure, including
the following information:
- Description of alternate operation procedures to
prevent undue hazards if the system fails
- Notification procedure for system shutdown or
failure
- System modification procedures
5.0 RISK ASSESSMENT (if applicable, appendix to the
Remediation Work Plan)
A. List of parameters to be addressed by Risk
Assessment
B. Description of proposed Risk Assessment
methodologies (e.g., types of modeling)
C. Identification of potential pathways of exposure
D. Identification of exposure assumptions
E. Environmental Fate and Transport data development
procedures
F. Summary table listing parameters and calculated
cleanup levels
G. List all Lines of Evidence to demonstrate that
exposure pathways are incomplete and will remain
incomplete (required for closure with levels above
RCG screening levels)
IV. REFERENCES
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. References used to prepare remediation work plan should
be cited or listed, including author, full title, publisher,
company, date, etc.
V. APPENDICIES
Report/Plan Element Present Location in Document
A. A QAPP is required for the remediation work plan. The
QAPP should contain all elements discussed on page 29
of the Remediation Closure Guide (RCG). If a QAPP was
submitted as part of the investigation report, it need not
be re-submitted.
Y
B. A site Health and Safety Plan is required. Y
VI. ENVIRONMENTAL RESTRICTIVE COVENANT OR ORDINANCE
Report/Plan Element Present
(Y,N, or NA)
Location in Document
Text of the restrictions or ordinance
Table of Last Known Concentrations of COC’s and the
closure standard
Site Plan showing covered areas with detailed boundary
description. IDEM data policy for reference:
http://www.in.gov/idem/files/olq_spatial_data_collection_stan
dards.pdf
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OTHER VRP REQUIREMENTS
COMMUNITY RELATIONS
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. Mailing list of nearby properties; interested community
groups; and local, state, and national officials (e.g.,
mayor, local newspaper, county health department,
representatives, and senators).
Y
B. Name and address of local library that will be the
repository for the Remediation Work Plan during the
public notice period.
Y
C. Copy of the RWP notification letter Y
PUBLIC MEETINGS
Report/Plan Element Present
(Y,N, or NA)
Location in Document
A. Discussion of plans to hold public information meetings
about the proposed remediation process.
B. Format of meetings.
C. Proposed public meeting schedule and notification
procedures.
D. Discussion of plans to prepare and distribute information
bulletins regarding the remediation system.
E. Description of the format and types of information
included in the bulletins.
F. Description of the types of media that will be used to
inform the general public (newspaper, radio, etc.).
G. Description of the type of information that will be released
to the media.
COMPLETION OF REMEDIAL ACTION
COMPLETION REPORT
Report/Plan Element Present Location in Document
A. Statement that a Completion Report detailing the
remediation system and confirmation sampling will be
submitted upon completion of the remediation to the
cleanup criteria.
Y
