Miss. Code. tit. 11, pt. 3, ch. 2, subch. 3, app 11-3-2-3-D
MISSISSIPPI DEPARTMENT OF ENVIRONMENTAL QUALITY BROWNFIELD VOLUNTARY CLEANUP PROGRAM ECOLOGICAL CHECKLIST
Section I- Facility Information
1. Name of Facility: _______________________________________________________
2. Location of Facility: _______________________________________________________
County: _______________________________________________________
3. Mailing Address: _______________________________________________________
4. Type of Facility: _______________________________________________________
5. Describe land use at and in the vicinity of the release site _______________________
____________________________________________________________________________
6. Attach a USGS topographic map of the facility and aerial and other photographs of the release site and surrounding areas.
Section 2-Surrounding Land Use Information
1. Describe land use adjacent to the facility. ___________________________________________________________________________
2. Provide the following information regarding the nearest water body:
Name of surface water body: ________________________________
Type of surface water body (pond, lake, river etc: ________________________________
3. Do any potentially sensitive environmental areas exist adjacent to or in proximity to the site, e.g., Federal and State parks, National and State Monuments, wetlands, etc. ____________________________________________________________________________
Section 3 - Release Information
1. Nature of release. ________________________________
2. Location of the release (within the facility) ________________________________
3. Location of the release with respect to the facility property boundaries:
___________________________________________________________________________
4. Chemicals of Concern (COC) known or suspected to have been released: __________________________________
____________________________________________________________________________
5. Indicate which media are known or suspected to be impacted and if sampling data are available:
____________________________________________________________________________
Soil 0-6 feet bgs yes no
____________________________________________________________________________
groundwater yes no
____________________________________________________________________________
surface water/sediment yes no ____________________________________________________________________________
6. Has migration occurred outside the facility property boundaries? yes no
If yes, describe the designated use of the land impacted: ____________________________________________________________________________
Section 4 - Criteria for Further Assessment
If the Area of Impact (AOI) meets all of the criteria presented below, then typically no further ecological evaluation shall be required. If the AOI does not meet all of the criteria, then a screening level ecological risk shall be conducted. The Submitter should make the initial decision regarding whether or not a screening level ecological risk assessment is warranted based on compliance of the AOI with criteria listed below. After review of the ecological checklist and other available site information, the Mississippi Department of Environmental Quality will make a final determination on the need for a screening level ecological risk assessment. If site conditions at the AOI change such that one or more of the criteria are not met, then a screening level ecological risk assessment shall be conducted.
The criteria for exclusion from further ecological assessment include:
The area of impacted soil is approximately 1 acre or less in size;
There is no current (or potential) release (via runoff or groundwater discharge) of COCs from the AOI to a surface water body;
Recreational species, commercial species, threatened or endangered species, and/or their habitats are not currently being exposed, or expected to be exposed, to COCs present at or migrating from the AOI; and
There are no obvious impacts to ecological receptors or their habitats.
Section 5 - Site Summary
The ecological checklist submittal shall include a site summary which presents sufficient information to verify that the AOI meets or does not meet the criteria for further assessment.
Section 6 - Submitter Information
Date: | |
Name of person submitting this check list: | |
Affiliation: | |
Signature | |
Additional Preparers: |
Miss. Code. tit. 11, pt. 3, ch. 2, subch. 3, app 11-3-2-3-D