Dry Cleaning Establishment Remediation Fund
Application and Instructions
State of Connecticut
Department of Economic and Community Development
Lilia Kieltyka, Program Manager
APPLICANT INFORMATION AMOUNT REQUESTED $
Applicant Name:
Applicant Mailing Address: Zip Code:
Telephone #:
Email Address:
Applicant FEIN#/SS#: CT Tax Registration#:
If applicant is part of the 2014 Intake Round, please indicate number and the submittal date.
DRY CLEANING BUSINESS INFORMATION
Establishment/Business Name:
Establishment Address: Zip Code:
Telephone#:
Establishment FEIN#/SS#: CT Tax Registration#:
APPLICANT REPRESENTATIVE INFORMATION (if applicable)
Representative Name: Title:
Representative Address:
Telephone #:
Email Address:
PROPERTY OWNER INFORMATION (list if different than applicant)
Property Owner Name: Title:
Property Owner Address: Zip Code:
Telephone#:
Email Address:
PROJECT INFORMATION
1. Site Information
Activities
Please check off which of the following needs will be addressed by this project:
Environmental Site Assessment (Phase I, II, III ESAs) & Preparation of a Remedial Action Plan (RAP) Note: The above must be completed in accordance with the most recent Connecticut Department of Energy and Environmental Protection (DEEP) Site Characterization Guidance Document, the DEEP Transfer Act Site Assessment Guidance Document, and the Regulations of Connecticut State Agencies (RCSA), Section 22a-133k (1-3), (the Remediation Standard Regulations).
Site Remediation
Other (please provide description)
Site Data
A. Please provide a brief physical description and land use history of the site
including:
(1) Historic uses (including a discussion of hazardous materials/waste handling, storage, and disposal practices);
(2) Identified and potential contamination at the site;
(3) Extent of pollution that has been identified, or may potentially be, migrating off site;
(4) Pollution impacts on public or private drinking water supply wells;
(5) Any public health and safety issues related to the site related pollution;
(6) Current operational practices, including best management practices in accordance with DEEP Garment Care Fact Sheets for active dry cleaning sites;
(8) Means and measures to prevent future spills or releases; and
(9) List of all environmental reports prepared for the property site.
NOTE: Attach a copy of all available technical plans and reports related to the investigation and remediation of the site (PDFs or CDs preferred).
B. DEEP Groundwater Classification & Drinking Water Supply Wells:
Please provide the groundwater classification where the Establishment is located, as indicated on the most recent DEEP map.
(GAA, GA, GB, etc):
Has a drinking water supply well receptor survey been completed? Yes No
If yes, were there any wells identified? Yes No
2. Environmental Compliance
A. Has any state, federal administrative agency, or court (Federal or State) issued any order or entered any judgment concerning a violation of any environmental law? (This applies to current and former property and business owners.) Yes No
If yes, attach the following information: jurisdiction, type of enforcement action, date, order/case/docket number, description of violation, status, and any other pertinent information.
B. List any property transfers of the property in the last 20 years.
List any transfers of the dry cleaning business in the last 20 years.
C. Responsible party for investigation and remediation (check one).
Current Property Owner
Former Property Owner
Current Business Owner
Former Business Owner
Other:
Include information to confirm the obligation of the responsible party.
For each property and/or business transfer, list on a separate sheet the following information: (1) the full legal names of the transferor (seller) and the transferee (buyer), (2) the transfer date, and (3) whether or not a Property Transfer Act form was filed with DEEP in accordance with CGS Section 22a-134.
For each property and/or business transfer, you must attach: (1) fully executed copies of the Transfer Act form (either Form I, II, III, or IV) and Environmental Conditions Assessment Form (ECAF) filed with the DEP and (2) copies of all correspondence from the DEEP regarding confirmation of receipt of the form filing and whether the DEEP delegated oversight of the investigation/ remediation to a Licensed Environmental Professional (LEP) or if the DEEP retained direct oversight.
D. Has the site been enrolled in the DEEP Voluntary Remediation Program (VRP) under either CGS Section 22a-133x or 22a-133y?
Yes, Date: No
If Yes – Has oversight of the investigation and remediation been delegated to an LEP by the DEEP?
Yes No, DEEP has retained direct oversight
If the site has been enrolled in a VRP, provide all documentation regarding enrollment, including: (1) the ECAF filed for VRP enrollment under CGS Section 22a-133x, (2) the RAP filed for VRP enrollment under CGS Section 22a-133y, and (3) all correspondence from DEEP regarding receipt of the ECAF or RAP and whether DEEP delegated oversight of the investigation/remediation to an LEP or if DEEP retained direct oversight.
E. Has the investigation and remediation of the site been verified as complete in accordance with the RSRs either by an LEP or the DEEP?
Yes, Date: No
If yes, provide a copy of the LEP verification report and correspondence from DEEP confirming acceptance of the LEP verification or approval of the investigation and remediation, copies of any notices of intent to audit the LEP verification by DEEP (if applicable), the DEEP audit findings letter (if applicable), and information regarding the resolution of the DEEP audit (if applicable).
F. Has an Environmental Land Use Restriction (ELUR) been filed with the DEEP and the municipality? Yes No
If yes, provide a copy of the ELUR, the Decision Document, the land deed, and any correspondence from DEEP and municipality regarding the ELUR filing.
G. Litigation Proceedings:
Are there any outstanding litigation proceedings related to this site?
Yes No
If yes, please provide information on type, parties involved, and status of litigation proceedings.
3. Estimated Project Cost/Finances
A. Project Description and Cost
Please complete the attached Project Financing Plan and Budget form. A project schedule is to be submitted which includes estimated project costs that correspond to the budget line items. The applicable backup documentation to support cost estimates shall also be provided to include:
· LEP proposals and/or scope of work
· Any associated contracts with environmental consulting firm
· Any applicable remediation bids or contracts
B. Applicant’s Financial Contribution
Attach invoices, cancelled checks, and receipts demonstrating that the applicant has invested at least $10,000 in eligible costs in the project.
4. REQUIRED DOCUMENTS:
A copy of the following documents must be included in order for the application to be considered complete:
Site Data (including copies of all reports)
Environmental Compliance Documentation
Project Financing Plan & Budget Form
Applicant's Financial Contribution, including copies of invoices and cancelled checks
Connecticut Dry Cleaning Surcharge Form OP-374 for the last four quarters
a signed statement that all relevant taxes are current
Certification by Applicant and Representative
It is hereby represented by the undersigned, as an inducement to the Department of Economic & Community Development to consider the financial assistance requested herein, that to the best of my knowledge and belief, no information or data contained in the application or in the attachments are in any way false or incorrect. The undersigned agrees that the Connecticut Department of Revenue Services, the Connecticut Department of Energy and Environmental Protection, and other agencies are hereby authorized now by the applicant and the representative, or anytime in the future, to give the Department of Economic & Community Development any and all information in connection with matters referred in this pre-application, including information concerning the payment of taxes by the applicant.
Applicant's Signature: Date:
Representative's Signature: Date:
Please be sure to include all required documents and submit to DECD when notified that sufficient funding is in place to accept your application:
Dry Cleaning Establishment Remediation Fund
DEPARTMENT OF ECONOMIC AND COMMUNITY DEVELOPMENT
505 Hudson Street, Hartford, CT 06106
Attention: Lilia Kieltyka
Telephone: (860) 270-8193
Rev. 12-2015