OKLAHOMA CORPORATION COMMISSION
PETROLEUM STORAGE TANK DIVISION
PAY FOR PERFORMANCE PROPOSAL AND WORK PLAN
PSTD Reviewer ______Approve [ ] Deny [ ] Date ______
1. CASE NUMBER Submitted to (PSTD P.E.A.):
FACILITY NUMBER To Fulfill Purchase Order:
This proposal is to be submitted after the Remediation Corrective Action Plan Proposal has been approved and after site clean-up levels have been approved. The data requested in the following sections will be used to evaluate the price of the approved soil, groundwater and/or free product remediation technique(s).
2. Facility Name:
Contact Person: , Phone #:
Street Address:
City:, County:
3. Owner/Operator:
Contact Person: , Phone #:
Street Address:
City:, State: Zip Code:
Owner/Operator’s Signature______Date ______
4. Environmental Consultant’s Signature ______Date ______
PSTD License Number: Expiration Date:
Environmental Consultant and Firm
Phone Numbers: Voice: Fax: Pager/Cell:
E-Mail Address:
5. Provide a summary of the approved remediation technology and/or techniques to be used.
6. List the Approved Risk Based Clean-up levels
ON-SITE OFF-SITE
Soil / Groundwater Soil / Groundwater
Benzene: / ppm Benzene: / ppm
Ethylbenzene: / ppm Ethylbenzene: / ppm
Toluene: / ppm Toluene: / ppm
Xylenes: / ppm Xylenes: / ppm
Naphthalene: / ppm Naphthalene: / ppm
7. Summarize the schedule for the ground water sampling. Include a list of the approved “Key Monitoring Wells,” “Key Free Product Monitoring Wells” and Compliance Monitoring Wells.
8. Provide a summary discussion or table for the remediation system operation and maintenance schedule. Include requirements and schedule for system sampling during this phase.
9. Provide a cost summary of the Pay for Performance Proposal for (1) design, (2) installation and (3) operation and maintenance of the approved remediation technique(s). Note the Advisory Council approved design costs that are to be calculated by multiplying the remediation system installation price or the remediation technique price plus its operation and maintenance price by 3.0%. This has a cap of $20,000. System design cost is to be deducted form system installation cost.
10. Discuss the remediation system operation and maintenance primary term and warranty period.
11. Diagrams and Schematics Needed
a. Diagrams and schematics needed provide diagrammatic schematics of the approved remediation system equipment.
b. A plan view showing the remediation system equipment area, piping and trench layout and system well surface and bottom hole locations
c. Include piping and trench cross-sectional views and other pertinent remediation equipment diagrams.
d. Provide a stratigraphic cross-section(s) showing the site lithology, representative cross-sectional views including all remediation system wells, monitoring wells, injection wells, extraction wells, recovery wells, etc. for the proposed remediation system. Show all former or proposed excavations, the most recent potentiometric surface, free product thickness and the known smear zone interval.
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Pay for Performance Proposal and Work Plan
Revised September 2006