Exhibit C LUC Inspection Form 2020.05.15_Draft Martinsburg VAMC.docx

Land Use Covenants West Virginia Department of Environmental Protection Office of Environmental Remediation

Land Use Covenant Inspection Form

The property owner is responsible for conducting annual inspections of the site and submitting this form to WVDEP no more than sixty (60) days before or after the anniversary date of the LUC recording. The person conducting the inspection should refer to the recorded LUC for details, including a map of the affected property and descriptions of the activity and use limitations and engineering controls.

Environmental Response Project Description

Site Description

Site ID Number 02-01-0012-0077-0000 Site Name AC Newton Baker Hospital (a.k.a. Martinsburg VAMC) County Berkeley

Address 64 Domiciliary Access Rd (alt: 510 Butler Avenue) City Martinsburg State

WV

Zip Code 25405

Property Owner on Land Use Covenant

Property Owner Name United States of America

Address 100 Penn Sq E City Philadelphia State

PA

Zip Code 19107

Annual Inspection – Records

Current Property Owner

Has property ownership transferred since LUC recording?

☐ No:

If contact information has not changed, skip to “Current Site Use.”

☐ Yes:

Provide new property owner contact information below.

Property Owner Name Property Owner Name

Address Address City City State State Zip Code Zip Code

Phone

Email

Current Site Use

Land Use (check all that apply) ☐ Agricultural ☐ Commercial ☐ Industrial ☐ Recreational ☐ Residential ☐ School ☐ Vacant ☒ Other

Provide brief description of current site use (including names of businesses located on property).

The facility (identified in tax records as the AC Newton Baker Hospital but currently known as the Martinsburg Veterans Affairs Medical Center [VAMC]) is located at the intersection of State Highway 115 and County Route 9/19 in Berkeley County, Martinsburg, West Virginia, approximately 4 miles southeast of the Martinsburg city limits. In tax records, the address is historically listed as 64 Domiciliary Access Road; currently, the primary address used is 510 Butler Avenue. The VAMC occupies approximately 169.3 acres of land and has a service area of more than 70,000 Veterans in West Virginia, Maryland, Virginia, and Pennsylvania. The facility, part of the VA Capitol Health Care Network (VISN 5), offers a comprehensive range of services, including internal medicine, ambulatory surgery, audiology and speech pathology, dental, nursing home, nutrition, podiatry, prosthetics, women's health, mental health, and rehabilitation medicine to United States Veterans. The facility has been in operation since the 1940s. Topography of the property is subdued, with an average elevation of 500 feet above mean sea level. The geographic coordinates for the hospital are 39° 25' 2.3"W latitude and 77° 54' 41.2"N longitude. These coordinates correspond to the center of the main hospital building, Building 500.

Annual Inspection – Property Observations

Activity and Use Limitations

The following activities on and uses of the property may result in excessive human exposure or in the release of a contaminant that was contained as part of the remedial action. Inspect the site to determine if any of the prohibited activities and uses listed below have occurred in the past year.

Engineering Controls

The following engineering controls have been installed at the property as a part of the remedy and are necessary to attain the designated remediation standard. They should be operated and maintained as necessary to protect their functional integrity. Inspect the site to determine if the engineering controls listed below are intact, functioning correctly, and being maintained as necessary.

Annual Inspection – Notes, Comments, or Concerns

Annual inspection of two engineering controls. Engineering Control #1 is an aeration tower (“air stripper”) that was integrated into the hospital’s drinking water treatment plant, which was brought online in 1994. The aeration tower was designed to remove low levels of chlorinated volatile organic compounds (CVOCs). Engineering Control #2 is a granular activated carbon (GAC) treatment system that was installed in 2011. The GAC treatment acts as a final polishing step and adds redundancy to the VA’s water treatment process following the aeration tower.

Annual inspections consist of confirming proper operation and maintenance of Engineering Controls #1 and #2 by collecting samples of the finished water and submitting them to a WV-certified laboratory for VOCs analysis.

Other inspections items may include performing periodic pump tests using PW-2 to determine if it can achieve historical pumping rates.

Person Conducting Inspection

Contact Information

Inspector Name Inspector Name Relationship to Property Relationship to Property

Mailing Address Address City City State State Zip Code

Phone (Phone Email Email

Statement of Affirmation

I affirm that the information provided in this Land Use Covenant Inspection Form, to the best of my knowledge and belief, is true, complete, and accurate.

Date

Signature

Date

Return completed and signed form, in addition to any attachments, electronically to DEPOERFileCopy@wv.gov, or mail to:

West Virginia Department of Environmental Protection

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