LYCOMINGCOUNTY
RESOURCE MANAGEMENT SERVICES
P. O. BOX 187
MONTGOMERY, PA 17752-0187
(800)326-9571 OR (570)547-2470
FAX: (570)547-6534
NONHAZARDOUS CONTAMINATED SOIL AND/OR DEBRIS
(PCB’s, Non-Petroleum Materials, Non-Virgin Petroleum Fuel)
A)GENERATOR OF THE WASTE:
1.Name of Company:
Mailing Address:
Zip:
Location of site if different from mailing address:
If a subsidiary, name of parent company:
- Company contact Person:
Title: Telephone:
Best time to call:
B)CONTRACTOR IN CHARGE OF CLEANUP:
1.Name of Company:
Mailing Address:
Zip:
- Company Contact Person:
Title: Telephone:
C)DISPOSAL FEES:
1. Who is responsible for disposal fees to the landfill?
Mailing Address:
- Contact Person:
Title: Telephone:
D)DESCRIPTION/LOCATION OF SOIL:
1.Quantity of soil to be disposed:
2.Type of Contaminant:
3.Source of contaminant:
4.Describe how the waste materials were generated. Give details of estimated volume of contaminant.
5.Are any absorbents (pads, booms, pigs, etc.) requested for disposal? If yes, give description.
6.Have any State of Federal agencies been involved in the cleanup? Yes No
If yes, please list the agency names(s), contact person(s), and an address and phone number for each.
7.Have any notices of violation been issued as a result of the event? Yes No
If yes, list below the date of the NOV(s), issuing agency name, contact person, address and phone number.
8.Has the soil been excavated? Yes No
9.Attach to this form, a copy of the Material Safety Data Sheet of the spilled product or other technical data sheets detailing the contaminant.
10.Please circle the item below that best describes the shape of the soil pile and indicate the appropriate dimensions.
H
H
L
W
D
H = H =
D = L =
W =
D2
W2
H L
H
W1
D1
H =
H =
L =
D1 =
W1 =
D2 =
W2 =
______
Signature Date
LYCOMING COUNTYLANDFILL
POLICY AND PROCEDURES FOR APPROVAL TO DISPOSE
NONHAZARDOUS CONTAMINATED SOIL
I.A questionnaire will be sent via FAX or mail; complete and return it as soon as possible.
II.The questionnaire will be reviewed by Landfill staff to determine if the soil is potentially acceptable for disposal.
III.Testing requirements on the soil vary by type and volume. Specific test requirements will be established upon review of the required data.
IV.Upon receipt of the test results, if required, Landfill staff will prepare a Form U application and send it to the generator for review, signatures and notarization.
V.Upon receipt of approval from DEP, the Landfill will notifiy the generator/contractor of disposal requirements. A Lycoming County Solid Waste Department Waste Manifest is required for each load of soil. The Landfill staff will assist with the completion of the manifests.
H:\WPData\ConSoil\NonHaz\Questionnnaire.doc