A5+-+NDRBCA+Report+Forms.xls

XLS spreadsheet 7 MB Posted Jul 15, 2025

Attached to: Lidgerwood 1Stop Tank Removal and Assessment
Solicitation number: 303-25-002
Issued by: Sargent County, North Dakota

About this file

Written by GovTribe AI · Jul 16, 2025

The document is a North Dakota Risk-Based Corrective Action (NDRBCA) Tier 1 Report Forms template developed by the North Dakota Department of Environmental Quality (NDDEQ) and EDGE Engineering & Science, LLC in December 2022. The comprehensive Excel-based forms are designed to standardize environmental site assessment and corrective action reporting, specifically for evaluating potential contamination at sites with potential environmental risks. The forms provide a structured approach to documenting site information, exposure models, groundwater and surface water protection assessments, and potential corrective actions across various scenarios including current and future residential, commercial, industrial, and construction worker exposures.

The report forms include detailed sections for analyzing environmental media such as surface soil, subsurface soil, groundwater, and potential contaminant pathways. The document supports a systematic evaluation of chemical concentrations against screening levels, with forms for comparing representative concentrations to Tier 1 Risk-Based Screening Levels (RBSLs) for different receptor types. The forms accommodate multiple remediation strategies including soil excavation, pump and treat activities, air sparge soil vapor extraction, LNAPL removal, enhanced monitored natural attenuation, and dual/multi-phase extraction. The template allows environmental professionals to comprehensively document site conditions, potential risks, and recommended management strategies for environmental contamination sites in North Dakota.

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A4+-+NDRBCA+Calculator.xls	XLS spreadsheet	Jul 15, 2025

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Title

NORTH DAKOTA RISK-BASED CORRECTIVE ACTION (NDRBCA)

TIER 1 REPORT FORMS

Considerable care was exercised in developing these Excel based forms. However, the North Dakota Department of Environmental Quality (NDDEQ) or EDGE makes no warranty regarding the accuracy of these forms and shall not be held liable for any damages resulting from its use.

Version 1.0, December 2022 Developed for:

North Dakota Department of Environmental Quality (NDDEQ)

Developed by:

EDGE Engineering & Science, LLC.

16285 Park Ten Pl #400, Houston, TX 77084 vpsambana@edge-es.com amsalhotra@edge-es.com

EXIT

CONTINUE

Tier1

CONCEPTUAL SITE MODEL

12 EXPOSURE MODEL

OFF-SITE RECEPTORS

ON-SITE RECEPTORS

15 TIER 1 EVALUATION (CURRENT AND ALLOWABLE FUTURE CONDITIONS)

OFF-SITE RECEPTORS

ON-SITE RECEPTORS

NDRBCA

TABLE OF CONTENTS

COVER PAGE

2 SITE INFORMATION

6 CHRONOLOGY OF EVENTS

8 LNAPL

10 GEOTECHNICAL PARAMETERS

4 UST STORAGE TANK TYPES

5 LAND USE (ON-SITE AND OFF-SITE)

1 EXECUTIVE SUMMARY

3 SITE DISCOVERY

7 COMPREHENSIVE SUMMARY OF DATA

9 SITE STRATIGRAPY & HYDROGEOLOGY

11 GROUNDWATER TO SURFACE WATER PATHWAY

TITLE

SUMMARY OF EXPOSURE MODEL

RESIDENT

COMMERCIAL/INDUSTRIAL WORKER

CONSTRUCTION WORKER

RESIDENT

COMMERCIAL/INDUSTRIAL WORKER

CONSTRUCTION WORKER

SUMMARY OF EXCEEDANCES

16 GROUNDWATER PROTECTON

17 SURFACE WATER PROTECTION

ON-SITE RECEPTORS

18 CONCLUSION AND RECOMMENDATION FOR TIER 1 EVALUATION

OFF-SITE RECEPTORS

19 CORRECTIVE ACTIONS

SOIL EXCAVATION

PUMP AND TREAT ACTIVITY

AIR SPARGE SOIL VAPOR EXTRACTION

SOIL VAPOR EXTRACTION BY VACUUM TRUCK

LNAPL REMOVAL

ENHANCED MONITORED NATURAL ATTENUATION

DUAL/MULTI PHASE EXTRACTION

INSTITUTIONAL CONTROLS, NOTICES,

AND RESTRICTIONS

REFERENCES

20 REFERENCES

13 GROUNDWATER PROTECTION

14 SURFACE WATER PROTECTION

CURRENT RESIDENT

CURRENT COMMERCIAL/INDUSTRIAL WORKER

FUTURE RESIDENT

FUTURE COMMERCIAL/INDUSTRIAL WORKER

CURRENT CONSTRUCTION WORKER

FUTURE CONSTRUCTION WORKER

CURRENT RESIDENT

CURRENT COMMERCIAL/INDUSTRIAL WORKER

FUTURE RESIDENT

FUTURE COMMERCIAL/INDUSTRIAL WORKER

CURRENT CONSTRUCTION WORKER

FUTURE CONSTRUCTION WORKER

COVER

North Dakota Risk-Based Corrective Action (NDRBCA) Tier 1 Report Forms

(NDRBCA Draft Tier 1 Report Forms, January 2023)

Site name:

Facility ID number (if any):

Site address:

Date site discovered:

Responsible Party Information:

Business name:

Contact person name:

Contact person address:

Contact person Phone No.:

Contact person Email ID:

Qualified consultant information:

Name:

Company name:

Address:

Phone No. & Email ID:

Date form completed:

Form completed by:

MAIN MENU

Group Box 24 Group Box 24 Group Box 24

TOC

		NDRBCA REPORT
		TABLE OF CONTENTS
		SITE INFORMATION AND TIER 1 FORMS (Continued)
			Form No.	Description		No. of
Pages	In report?
			1.	Executive Summary
		CONCEPTUAL SITE MODEL
			2.	Site Information
			3.	Site Discovery
			4.	Underground Storage Tank Types
			5.	Land Use (On-Site and Off-Site)
			6.	Chronology of Events
			7.	Comprehensive Summary of Data
			8.	Light Non-Aqueous Phase Liquid (LNAPL)
			9.	Site Stratigraphy and Hydrogeology
			10.	Geotechnical Parameters
			11.	Groundwater to Surface Water Protection Pathway
		EXPOSURE MODEL
			12.	Exposure Model
				On-Site Resident (Current and Reasonably Anticipated Future Conditions)
				On-Site Commercial/Industrial Worker (Current and Reasonably Anticipated Future Conditions)
				Off-Site Resident (Current and Reasonably Anticipated Future Conditions)
				Off-Site Commercial/Industrial Worker (Current and Reasonably Anticipated Future Conditions)
				Summary of Exposure Model (Complete Routes of Exposure Highlighted)
			13.	Consideration of Groundwater Protection Pathway
			14.	Consideration of Surface Water Protection Pathway
		TIER 1 EVALUATION
			15.	Comparison of Representative Site Concentrations with Tier 1 RBSLs
				On-Site Resident (Current Conditions)
				On-Site Commercial/Industrial Worker (Current Conditions)
				On-Site Resident (Reasonably Anticipated Future Conditions)
				On-Site Commercial/Industrial Worker (Reasonably Anticipated Future Conditions)
				Off-Site Resident (Current Conditions)
				Off-Site Commercial/Industrial Worker (Current Conditions)
				Off-Site Resident (Reasonably Anticipated Future Conditions)
				Off-Site Commercial/Industrial Worker (Reasonably Anticipated Future Conditions)
				Summary of Exceedances
			16.	Comparison of Representative Site Concentrations with Tier 1 Groundwater Protection Target Concentrations
			17.	Comparison of Representative Site Concentrations with Tier 1 Surface Water Protection Target Concentrations
			18(a).	Conclusion and Recommendation (On-Site)
			18(b).	Conclusion and Recommendation (Off-Site)
		NDRBCA REPORT
		TABLE OF CONTENTS
		SITE INFORMATION AND TIER 1 FORMS (Continued)
		No.		Description		No. of
Pages	In report?
		RISK MANAGEMENT PLAN
			19(a).	Corrective Action (Soil Excavation)
			19(b).	Corrective Action (Pump and Treat)
			19(c).	Corrective Action (Air Sparge Soil Vapor Extraction)
			19(d).	Corrective Action (Soil Vapor Extraction By Vacuum Truck)
			19(e).	Corrective Action (LNAPL Removal)
			19(f).	Corrective Action (Enhanced Monitored Natural Attenuation)
			19(g).	Dual/Multi Phase Extraction
			19(h).	Corrective Action (Environmental Covenant)
			20.	References
		TIER 2 EVALUATION
			21.	Tier 2 Fate and Transport and Building Parameters
			22.	Justification for Tier 2 Fate and Transport and Building Parameters
			23.	Tier 2 Exposure Factors
			24.	Justification for Tier 2 Exposure Factors
			25.	Comparison of Representative Site Concentrations with Tier 2 SSTLs
				On-Site Resident (Current Conditions)
				On-Site Commercial/Industrial Worker (Current Conditions)
				On-Site Construction Worker (Current Conditions)
				On-Site Resident (Reasonably Anticipated Future Conditions)
				On-Site Commercial/Industrial Worker (Reasonably Anticipated Future Conditions)
				On-Site Construction Worker (Reasonably Anticipated Future Conditions)
				Off-Site Resident (Current Conditions)
				Off-Site Commercial/Industrial Worker (Current Conditions)
				Off-Site Construction Worker (Current Conditions)
				Off-Site Resident (Reasonably Anticipated Future Conditions)
				Off-Site Commercial/Industrial Worker (Reasonably Anticipated Future Conditions)
				Of-Site Construction Worker (Reasonably Anticipated Future Conditions)
				Summary of Exceedances
			26.	Comparison of Representative Site Concentrations with Tier 2 Groundwater Protection Target Concentrations
			27.	Comparison of Representative Site Concentrations with Tier 2 Groundwater Protection Target Concentrations
			28.	Conclusions and Recommendations for On-Site and Off-Site Receptors
		LIST OF TABLES
			1(a).	Comprehensive Soil Analytical Data for Primary Chemicals
			1(b).	Comprehensive Soil Analytical Data for Secondary Chemicals
			1(c).	Soil Analytical Data for Total Petroleum Hydrocarbons
			1(d).	Field PID Readings Measured During Soil Boring Installation
			2.	Monitoring Well Construction Details
			3.	Gauging Data for Monitoring Wells
			4.	Light Non-Aqueous Phase Liquid (LNAPL) Recovery
			5(a).	Comprehensive Groundwater Analytical Data for Primary Chemicals
			5(b).	Comprehensive Groundwater Analytical Data for Secondary Chemicals
			6(a).	Comprehensive Soil Vapor Analytical Data for Primary Chemicals
			6(b).	Comprehensive Soil Vapor Analytical Data for Secondary Chemicals
			7(a).	Comprehensive Subslab Vapor Analytical Data for Primary Chemicals
			7(b).	Comprehensive Subslab Vapor Analytical Data for Secondary Chemicals
			8(a).	Comprehensive Indoor Air Analytical Data for Primary Chemicals
			8(b).	Comprehensive Indoor Air Analytical Data for Secondary Chemicals
			Additional Tables
		NDRBCA REPORT
		TABLE OF CONTENTS
		SITE INFORMATION AND TIER 1 FORMS (Continued)
			All maps/figures submitted to the EGLE must include a bar scale, legend, north arrow. Include maps showing all sampling points (soil, groundwater, soil vapor, and subslab vapor, and ambient air) and date prepared.
		No.		Description			In report?
		LIST OF FIGURES
			1.	Site Location Map	Figure No.
			2.	Site Map Showing Site Boundaries and Past and Present Site Features	Figure No.
			3.	Site Map Showing Location and Depths of On-Site and Off-Site Subsurface Utilities	Figure No.
			4.	Land Use Map (Radius of 1,000 feet)	Figure No.
			5.	Site Map Showing Buildings within 1,000 ft of source	Figure No.
			6.	Site Map Showing Soil Boring and Monitoring Well Locations (including drinking water wells onsite)	Figure No.
			7.	Figure Showing Suspected Source(s) of LNAPL	Figure No.
			8.	Figures Showing Soil Stratigraphy and Cross-Sections	Figure No.
			9.	Figure Showing Groundwater Gradients or Water Level Contour Map
			10.	Figure Showing Soil Concentrations or Contour Map	Figure No.
			11.	Figure Showing Groundwater Concentrations or Contour Map	Figure No.
			12.	Figure Showing Areas of Excavation	Figure No.
			13.	Figure Showing Location of Post Excavation Soil Samples	Figure No.
			14.	Figure Showing Location of Pumping Wells	Figure No.
			15.	Figure Showing Location of Vapor Extraction Points	Figure No.
			16.	Figure Showing Location of Injection Points for Enhanced Natural Attenuation	Figure No.
			17.	Figure Showing Location of Dual Phase Extraction Wells	Figure No.
			18.	Site Map Showing the Surface Water Feature including Storm Water Sewer	Figure No.
			19.	Figure for Cross Section Showing the Groundwater Table and Bottom of Surface Water Feature	Figure No.
			20.	Figure showing the Location(s) of the Soil source(s), Location of POE, and Location(s) of POD for Groundwater Protection	Figure No.
			21.	Figure showing the location(s) of the soil source(s), location of POE, and location(s) of POD for Surface Water Protection	Figure No.
			Additional Figures
					Figure No.
					Figure No.
					Figure No.
					Figure No.
					Figure No.
					Figure No.
		NDRBCA REPORT
		TABLE OF CONTENTS
		SITE INFORMATION AND TIER 1 FORMS (Continued)
		No.		Description		No. of
Pages	In report?
		ATTACHMENTS
			1.	Documentation of LNAPL Disposal Manifests
			2.	Soil Boring Logs
			3.	Monitoring Well Construction Logs
			4.	Documentation for Calculation of Vertical Gradients
			5.	Documentation of Soil and Water Disposal Manifests
			6.	Operation and Maintenance Plan for Each Corrective Action Technology (as appropriate)
			7.	Monitoring Plan for Each Corrective Action Technology (as appropriate)
			8.	Documentation for Calculation of Representative Concentrations
			9.	Laboratory Analytical Report
			10.	Documentation of Environmental Covenants
			11.	Output Tables from the NDRBCA Computational Coftware
			Additional Attachments

&CPage &P of &N

MAIN MENU

FORM 1

NDRBCA REPORT										FORM NO. 1
Facility ID number (if any):			Site address:
Date form completed:			Form completed by:
EXECUTIVE SUMMARY
Site address
Status of facility				Active		Inactive
Is off-site soil impacted?				Yes		No
Is off-site soil data available?				Yes		No
Is groundwater impacted?				On-site		Off-site
Groundwater flow direction
Shallowest historical depth to groundwater					ft bgs;	Period			to
Average historical depth to groundwater					ft bgs;	Period			to
Has the source of release been identified?
Was LNAPL ever detected in a well/excavation?
Was LNAPL removed?
When was LNAPL last detected?				Date
Has surface water been impacted?
Has a water supply well been impacted?
Is there a public water supply well within 1,000 ft?				Distance			ft;	Direction
Is there a private water supply well within 1,000 ft?				Distance			ft;	Direction
RECOMMENDATIONS
		TIER 1 Evaluation				TIER 2 Evaluation
		Closure under Tier 1				Closure under Tier 2
		Remediate to Tier 1				Remediate to Tier 2
		Perform monitoring				Perform monitoring
		Go to Tier 2				Go to Tier 3
BASIS OF RECOMMENDATION AND ADDITIONAL NOTES
REPORT PREPARED BY
	I attest that the information upon which this report is based is complete and true to the best of my knowledge.
	Signature of Owner or Representative			Print Owner or Representative Name					Date
	Name of Company			Address
	Email Address			Phone Number

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FORM 2

NDRBCA REPORT									FORM NO. 2
Facility ID number (if any):			Site address:
Date form completed:			Form completed by:
SITE INFORMATION
Site name:
Facility ID number (if any):
Site address:
Date site discovered:
Responsible Party Information:
Business name:
Contact person name:
Contact person address:
Contact person Phone No.:
Contact person Email ID:
		SITE TYPE				OPERATING?
		Petroleum UST site
		Petroleum AST site
		Oil and gas facility/site
		Manufacturing facility
		Pesticide facility
		Dry cleaning facility
		Land fill
		Other
	For facility type identified as "other", discuss specific details below:
	Subsurface Utilities
	Have the on-site subsurface utilities been identified?			YES		NO
	Range of depth to utilities (ft bgs)
	Type of utilities
	Have the utilities been screened for vapor levels?				YES	NO
	If YES, attach documentation of vapor monitoring results.
	If drinking water lines potentially impacted, has drinking water been tested for VOCs?						YES	NO
	If YES, attach documentation of drinking water monitoring results.
	Discuss below how site was discovered and historic site use
ADDITIONAL NOTES FOR FACILITY AND UTILITIES
Attachments: (1) Figure 1 Site location map; (2) Figure 2 Site map showing property boundaries, past and current site features (e.g., storage systems, process areas, distribution areas, location of release, location of on and off-site monitoring points, location of public and private water wells within 1,000 ft, location of surface water features within 1,000 ft, ecological receptors within 1,000 ft, location of excavation, and location of remedial system, if any); (3) Figure 3 Site map showing locations and depths of on-site subsurface utilities

C/ NC*

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FORM 3

NDRBCA REPORT		FORM NO. 3
Facility ID number (if any):	Site address:
Date form completed:	Form completed by:
SITE DISCOVERY
Instructions: Describe (i) site operations, (ii) how the site was discovered (e.g., sheen in utilities and observation wells, sudden loss of product in tanks, Phase I or II investigations as part of real estate transactions, accidental release, citizen compliant of odors) (iii) when was the release occurred, (iv) location of release, (v) chemicals stored, used, and released at the facility, (vi) quantity released (if known) etc.
Attachments: None.

C/ NC*

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FORM 4

NDRBCA REPORT										FORM NO. 4
Facility ID number (if any):						Site address:
Date form completed:						Form completed by:
UNDERGROUND STORAGE TANK TYPES
	New Tank ID Number(s)	Product	Capacity	In Use		Installation Date	Removal Date	Closure in Place Date	Temporarily closed
				Yes	No
							1
	Tank number(s) identified with " * " are associated with the confirmed release(s).
ADDITIONAL NOTES
Attachment: Figure 2 Site Map Showing Site Boundaries and Past and Present Site Features

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FORM 5

	NDRBCA REPORT					FORM NO. 5
	Facility ID number (if any):			Site address:
	Date form completed:			Form completed by:
	LAND USE (ON-SITE AND OFF-SITE)
		Current On-site Land Use			Allowable Future On-site Land Use
		Residential			Residential
		Non-residential			Non-residential
		Other (please explain below)			Other (please explain below)
		Is site located in wellhead
protection area?			Is site located in wellhead

protection area?

- Describe the current and potential future use of the on-site land and surrounding land, groundwater, surface water, and sensitive habitats within 1,000 ft of the site boundary and in all directions (N, S, E, and W).

Attachments: (1) Figure 4 Land use map (Radius of 1,000 feet); (2) Figure 5 Site map showing buildings within 1,000 ft of source

C/ NC*

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FORM 6(1)

NDRBCA REPORT				FORM NO. 6
Facility ID number (if any):		Site address:
Date form completed:		Form completed by:
CHRONOLOGY OF EVENTS
Date	Instructions: Describe site characterization, sampling, and remediation activities including installation of soil borings, monitoring wells, soil vapor monitoring points, subslab vapor points, slug tests, institutional controls, LNAPL removal, etc.
Include completed Form 20 for list of references.			Page 1 of

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FORM 6(2)

NDRBCA REPORT				FORM NO. 6
Facility ID number (if any):		Site address:
Date form completed:		Form completed by:
CHRONOLOGY OF EVENTS
Date	Instructions: Describe site characterization, sampling, and remediation activities including installation of soil borings, monitoring wells, soil vapor monitoring points, subslab vapor points, slug tests, institutional controls, LNAPL removal, etc.
Include completed Form 20 for list of references.			Page 2 of

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FORM 7

NDRBCA REPORT					FORM NO. 7
Facility ID number (if any):		Site address:
Date form completed:		Form completed by:
COMPREHENSIVE SUMMARY OF DATA
No. of soil borings advanced
Range of depth of soil borings			ft bgs to	ft bgs
No. of soil samples collected from soil borings and analyzed
No. of permanent groundwater monitoring wells installed
No. of permanent active groundwater monitoring wells
No. of abandoned permanent groundwater monitoring wells
No. of nested permanent groundwater monitoring well pairs
No. of temporary groundwater monitoring wells installed
No. of temporary groundwater monitoring wells still active
Range of depth of permanent groundwater monitoring wells			ft bgs to	ft bgs
No. of piezometers installed
No. of piezometers still active
No. of LNAPL recovery wells
No. of soil vapor extraction wells
No. of soil vapor monitoring ports installed
No. of soil vapor samples analyzed (and no. of events)
No. of subslab vapor monitoring points installed
No. of subslab vapor samples analyzed (and no. of events)
No. of ambient air samples analyzed by laboratory (not PIDs)
No. of soil samples analyzed for geotechnical parameters
No. of tanks removed
No. of soil samples collected during tank removal
No. of soil samples collected post excavation, if any
	Please confirm that the above information is consistent with the chronology, figures, and tables. For example, if the number of monitoring wells installed is 10, Table 2 must list 10 wells, Figure 6 must show 10 wells, Attachment 3 must show 10 well construction details, and the chronology must match the dates of well installation shown on Table 2. Any inconsistencies must be explained in the space provided below. The total number of samples must include the duplicates and also the number of duplicates.
ADDITIONAL NOTES COMPREHENSIVE SUMMARY OF DATA
Attachments: Tables 1 to 8 (see table of contents for specifics)

C/ NC*

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Form 8

NDRBCA REPORT							FORM NO. 8
Facility ID number (if any):				Site address:
Date form completed:				Form completed by:
LIGHT NON-AQUEOUS PHASE LIQUID (LNAPL)
	Has LNAPL been encountered in any monitoring well?			Yes	No
	(Note if No, proceed to the next report form)
	Type of product released
	Estimated quantity of product released
	List the monitoring wells that have contained measurable LNAPL
	Date when LNAPL was last measured in a monitoring well
	List the monitoring wells currently containing measurable LNAPL
	Maximum thickness	feet	Well ID			Date
	Include attachments to provide relevant supporting information, as appropriate.
SUMMARY OF LNAPL REMOVAL
	Has LNAPL removal been conducted?		Yes	No
	Method of removal (bailer, pump, etc.)?
	Frequency of removal (weekly, monthly, etc.)
	Total number of recovery events
	Total volume of water recovered with LNAPL
	Total volume of LNAPL recovered
	Date of most recent LNAPL removal activity
	Describe how the recovered LNAPL was disposed
	If LNAPL removal was conducted complete Form 19(e).
ADDITIONAL NOTES FOR LNAPL
Attachments: (1) Table 3: Gauging data for monitoring wells; (2) Table 4: LNAPL recovery; (3) Figure 7: Site map showing suspected source(s) of LNAPL and (4) Attachment 1: Completed LNAPL disposal manifests

C/ NC*

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FORM 9

NDRBCA REPORT						FORM NO. 9
Facility ID number (if any):			Site address:
Date form completed:			Form completed by:
SITE STRATIGRAPHY AND HYDROGEOLOGY
STRATIGRAPHY
	Depth [feet]	Type of Soil
	Predominant soil type in vadose zone
	Predominant soil type in saturated zone
HYDROGEOLOGY
		Zone 1		Zone 2	Zone 3
	Range of measured groundwater level [ft bgs]
	Average depth to stabilized water level [ft bgs]
	Estimated depth to top of zone (ft bgs)
	Estimated depth to bottom of zone (ft bgs)
	Estimated thickness of water bearing zone (ft)
	Aquifer type (confined/unconfined/perched, etc.)
	Predominant flow direction
	Hydraulic gradient (i) [--]
	Hydraulic conductivity (K) [cm/year]
	Hydraulic conductivity test method
	Darcy velocity (K × i) [cm/year - calculated]
	Predominant vertical gradient (Zone 1 to Zone 2) [--]
	Predominant vertical gradient (Zone 2 to Zone 3) [--]
	Show details of vertical gradient calculations in Attachment 4, if available.
ADDITIONAL NOTES FOR SITE STRATIGRAPHY AND HYDROGEOLOGY
Attachments: (1) Table 3: Gauging data for monitoring wells; (2) Figure 8: site stratigraphy and cross sections; ; (3) Figure 9: groundwater gradients or water level contour map; (4) Attachment 2: Soil boring logs; (5) Attachment 3: Monitoring well construction logs; (6) Attachment 4: Documentation for calculation of vertical gradients

C/ NC*

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FORM 10

NDRBCA REPORT							FORM NO. 10
Facility ID number (if any):			Site address:
Date form completed:			Form completed by:
GEOTECHNICAL PARAMETERS
VADOSE ZONE
		Mean/Range				Method
	Dry bulk density (ρb) [g/cm3]			Estimated	Measured			2.100
	Estimated porosity (θT) [cm3/cm3]			Estimated	Measured			0.213
	Water content (θw)[cm3/cm3]			Estimated	Measured			0.056
	Fractional organic carbon content (foc) [g-C/g-soil]			Estimated	Measured			0.003	0.002	0.004
	Provide details of measured values below.
SATURATED ZONE
		Values/Range				Method
	Dry bulk density (ρb) [g/cm3]			Estimated	Measured
	Estimated porosity (θT) [cm3/cm3]			Estimated	Measured
	Water content (θw)[cm3/cm3]			Estimated	Measured
	Fractional organic carbon content (foc) [g-C/g-soil]			Estimated	Measured
	Provide details of measured values below.
ADDITIONAL NOTES GEOTECHNICAL PARAMETERS
Attachments: (1) Attachment 2: Soil boring logs; (2) Attachment 3: Monitoring well construction log

C/ NC*

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FORM 11

NDRBCA REPORT					FORM NO. 11
Facility ID number (if any):		Site address:
Date form completed:		Form completed by:
GROUNDWATER TO SURFACE WATER PATHWAY
	Has the plume impacted the surface water body?		Yes	No
	Are surface waters of the state located within 1,000 ft downgradient of the source area?		Yes	No
	(If No, proceed to the next Form)
	Please describe the surface water body
	Approximate elevation of bottom of surface water body (ft msl)
	Is the approximate bottom of surface water body above the groundwater table?		Yes	No
	(If Yes, groundwater to surface water pathway is not complete)
	Is groundwater to surface water pathway complete?		Yes	No
	Provide justification for your choice:
ADDITIONAL NOTES FOR GROUNDWATER TO SURFACE WATER
Attachments: (1) Figure 18: Site map showing the surface water feature including storm water sewer; (2) Figure 19: Cross-section showing the groundwater table and bottom of surface water feature

C/ NC*

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FORM 12(1)

	NDRBCA REPORT				FORM NO. 12 - ON-SITE RESIDENT
	Facility ID number (if any):			Site address:
	Date form completed:			Form completed by:
	EXPOSURE MODEL - ON-SITE RESIDENT
	MEDIA AND ROUTE
OF EXPOSURE	CURRENT CONDITIONS		ALLOWABLE FUTURE CONDITIONS
		C/NC	Justification for Route of Exposure	Monitoring Points

Exposure Domain for Calculating RC* C/NC Justification for Route of Exposure Monitoring Points Exposure Domain for Calculating RC*

SURFACE SOIL (0 to 2 ft bgs)
Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates	1	C		1	C
		NC			NC
SUBSURFACE SOIL (>2 ft bgs to water table) (Recommendation is to Use Soil Vapor RBTLs)
Indoor inhalation of vapors	0	C		1	C
		NC			NC
GROUNDWATER
Domestic use of water (ingestion of and dermal contact with, and inhalation of vapors due to indoor water use)	0	C		1	C
		NC			NC
Indoor inhalation of vapors from groundwater	2	C		1	C
		NC			NC
Notes:
C : Complete Pathway; NC : Not Complete			RC: Representative concentration			Page 1 of
*: If space is not sufficient to list the monitoring points within the exposure domain, then please include the list of monitoring points in an attachment/table showing each exposure domain and monitoring points within the domain.
Attachments: (1) Figure 6: Site map showing soil boring and monitoring well locations (including drinking water wells onsite); (2) Figure 10: Soil Concentrations or Contour Map; (3) Figure 11: Groundwater Concentrations or Contour Map

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FORM 12(2)

	NDRBCA REPORT				FORM NO. 12 - EXPOSURE MODEL - ON-SITE COMMERCIAL/INDUSTRIAL WORKER
	Facility ID number (if any):			Site address:
	Date form completed:			Form completed by:
	EXPOSURE MODEL - ON-SITE COMMERCIAL/INDUSTRIAL WORKER
	MEDIA AND ROUTE
OF EXPOSURE	CURRENT CONDITIONS		ALLOWABLE FUTURE CONDITIONS
		C/NC	Justification for Route of Exposure	Monitoring Points

Exposure Domain for Calculating RC* C/NC Justification for Route of Exposure Monitoring Points Exposure Domain for Calculating RC*

SURFACE SOIL (0 to 2 ft bgs)
Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates	1	C		1	C
		NC			NC
SUBSURFACE SOIL (>2 ft bgs to water table) (Recommendation is to Use Soil Vapor RBTLs)
Indoor inhalation of vapors	0	C		1	C
		NC			NC
GROUNDWATER
Indoor inhalation of vapors from groundwater	2	C		1	C
		NC			NC
Notes:
C : Complete Pathway; NC : Not Complete			RC: Representative concentration			Page 2 of
*: If space is not sufficient to list the monitoring points within the exposure domain, then please include the list of monitoring points in an attachment/table showing each exposure domain and monitoring points within the domain.
Attachments: (1) Figure 6: Site map showing soil boring and monitoring well locations (including drinking water wells onsite); (2) Figure 10: Soil Concentrations or Contour Map; (3) Figure 11: Groundwater Concentrations or Contour Map

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FORM 12(3)

		NDRBCA REPORT					FORM NO. 12 - ON-SITE CONSTRUCTION WORKER
		Facility ID number (if any):				Site address:
		Date form completed:				Form completed by:
		EXPOSURE MODEL - ON-SITE CONSTRUCTION WORKER
		MEDIA AND ROUTE
OF EXPOSURE		CURRENT CONDITIONS			ALLOWABLE FUTURE CONDITIONS
				C/NC	Justification for Route of Exposure	Monitoring Points Exposure Domain
for Calculating RC*	C/NC		Justification for Route of Exposure	Monitoring Points Exposure Domain

for Calculating RC*

SOIL UP TO DEPTH OF CONSTRUCTION
Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates	1	C		1	C
		NC			NC
Notes:
C : Complete Pathway; NC : Not Complete			RC: Representative concentration			Page 3 of
*: If space is not sufficient to list the monitoring points within the exposure domain, then please include the list of monitoring points in an attachment/table showing each exposure domain and monitoring points within the domain.
Attachments: (1) Figure 6: Site map showing soil boring and monitoring well locations (including drinking water wells onsite); (2) Figure 10: Soil Concentrations or Contour Map;

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FORM 12(4)

	NDRBCA REPORT				FORM NO. 12 - OFF-SITE RESIDENT
	Facility ID number (if any):			Site address:
	Date form completed:			Form completed by:
	EXPOSURE MODEL - OFF-SITE RESIDENT
	MEDIA AND ROUTE
OF EXPOSURE	CURRENT CONDITIONS		ALLOWABLE FUTURE CONDITIONS
		C/NC	Justification for Route of Exposure	Monitoring Points

Exposure Domain for Calculating RC* C/NC Justification for Route of Exposure Monitoring Points Exposure Domain for Calculating RC*

SURFACE SOIL (0 to 2 ft bgs)
Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates	1	C		1	C
		NC			NC
SUBSURFACE SOIL (>2 ft bgs to water table) (Recommendation is to Use Soil Vapor RBTLs)
Indoor inhalation of vapors	0	C		1	C
		NC			NC
GROUNDWATER
Domestic use of water (ingestion of and dermal contact with, and inhalation of vapors due to indoor water use)	0	C		1	C
		NC			NC
Indoor inhalation of vapors from groundwater	2	C		1	C
		NC			NC
Notes:
C : Complete Pathway; NC : Not Complete			RC: Representative concentration			Page 4 of
*: If space is not sufficient to list the monitoring points within the exposure domain, then please include the list of monitoring points in an attachment/table showing each exposure domain and monitoring points within the domain.
Attachments: (1) Figure 6: Site map showing soil boring and monitoring well locations (including drinking water wells onsite); (2) Figure 10: Soil Concentrations or Contour Map; (3) Figure 11: Groundwater Concentrations or Contour Map

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FORM 12(5)

	NDRBCA REPORT				FORM NO. 12 - EXPOSURE MODEL - OFF-SITE COMMERCIAL/INDUSTRIAL WORKER
	Facility ID number (if any):			Site address:
	Date form completed:			Form completed by:
	EXPOSURE MODEL - OFF-SITE COMMERCIAL/INDUSTRIAL WORKER
	MEDIA AND ROUTE
OF EXPOSURE	CURRENT CONDITIONS		ALLOWABLE FUTURE CONDITIONS
		C/NC	Justification for Route of Exposure	Monitoring Points

Exposure Domain for Calculating RC* C/NC Justification for Route of Exposure Monitoring Points Exposure Domain for Calculating RC*

SURFACE SOIL (0 to 2 ft bgs)
Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates	1	C		1	C
		NC			NC
SUBSURFACE SOIL (>2 ft bgs to water table) (Recommendation is to Use Soil Vapor RBTLs)
Indoor inhalation of vapors	0	C		1	C
		NC			NC
GROUNDWATER
Indoor inhalation of vapors from groundwater	2	C		1	C
		NC			NC
Notes:
C : Complete Pathway; NC : Not Complete			RC: Representative concentration			Page 5 of
*: If space is not sufficient to list the monitoring points within the exposure domain, then please include the list of monitoring points in an attachment/table showing each exposure domain and monitoring points within the domain.
Attachments: (1) Figure 6: Site map showing soil boring and monitoring well locations (including drinking water wells onsite); (2) Figure 10: Soil Concentrations or Contour Map; (3) Figure 11: Groundwater Concentrations or Contour Map

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FORM 12(6)

		NDRBCA REPORT					FORM NO. 12 - OFF-SITE CONSTRUCTION WORKER
		Facility ID number (if any):				Site address:
		Date form completed:				Form completed by:
		EXPOSURE MODEL - OFF-SITE CONSTRUCTION WORKER
		MEDIA AND ROUTE
OF EXPOSURE		CURRENT CONDITIONS			ALLOWABLE FUTURE CONDITIONS
				C/NC	Justification for Route of Exposure	Monitoring Points Exposure Domain
for Calculating RC*	C/NC		Justification for Route of Exposure	Monitoring Points Exposure Domain

for Calculating RC*

SOIL UP TO DEPTH OF CONSTRUCTION
Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates	1	C		1	C
		NC			NC
Notes:
C : Complete Pathway; NC : Not Complete			RC: Representative concentration			Page 6 of
*: If space is not sufficient to list the monitoring points within the exposure domain, then please include the list of monitoring points in an attachment/table showing each exposure domain and monitoring points within the domain.
Attachments: (1) Figure 6: Site map showing soil boring and monitoring well locations (including drinking water wells onsite); (2) Figure 10: Soil Concentrations or Contour Map;

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FORM 12(7)

FORM NO. 17 - SUMMARY OF EM

NDRBCA REPORT

FORM NO. 12 - SUMMARY OF EM

Facility ID number (if any):

Site address:

Date form completed:

Form completed by:

SUMMARY OF EXPOSURE MODEL (COMPLETE ROUTES OF EXPOSURE HIGHLIGHTED)

MEDIA AND ROUTE

OF EXPOSURE

ON-SITE RECEPTOR

OFF-SITE RECEPTOR

CURRENT CONDITIONS

ALLOWABLE FUTURE CONDITIONS

CURRENT CONDITIONS

ALLOWABLE FUTURE CONDITIONS

Resident

Commercial/Industrial Worker

Construction Worker

Resident

Commercial/Industrial Worker

Construction Worker

Resident

Commercial/Industrial Worker

Construction Worker

Resident

Commercial/Industrial Worker

Construction Worker

SURFICIAL SOIL FOR RESIDENT AND COMMERCIAL/INDUSTRIAL WORKER AND SOIL UPTO DETPH OF CONSTRUCTION FOR CONSTRUCTION WORKER

Ingestion of and dermal contact with, and inhalation of vapors and particulates

SUBSURFACE SOIL (>2 ft bgs to water table) (Recommendation is to Use Soil Vapor RBTLs)

Indoor inhalation of vapors

GROUNDWATER

Domestic use of water (ingestion of and dermal contact with, and inhalation of vapors due to indoor water use)

Indoor inhalation of vapors

Notes

C: Complete Pathway NC: Not Complete

NA: Not applicable

Page 7 of

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FORM 13

NDRBCA REPORT						FORM NO. 13
Facility ID number (if any):				Site address:
Date form completed:				Form completed by:
CONSIDERATION OF GROUNDWATER PORTECTION PATHWAY
Per Section 5.3.3 of NDRBCA Guidance document this pathway requires the (i) location of point of exposure (POE), (ii) acceptable concentration at POE, and (iii) location of point of demonstration (POD). Based on these RBTLs are developed for (i) groundwater POD, (ii) subsurface soil, and (iii) surface soil.
For this pathway provide the following:
	Location of POE:		feet (ft) from downgradient edge of source
	Concentration at POE:	MCL	Tapwater RBTL		Other
	Location of POD (include well ID and location):
	Note, there may be multiple PODs.
ADDITIONAL NOTES FOR CONSIDERATION OF GROUNDWATER PROTECTION PATHWAY
Attachments: (1): Figure 20: Figure showing the location(s) of the soil source(s), location of POE, and location(s) of POD for Groundwater Protection

C/ NC*

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FORM 14

NDRBCA REPORT						FORM NO. 14
Facility ID number (if any):			Site address:
Date form completed:			Form completed by:
CONSIDERATION OF SURFACE WATER PROTECTION PATHWAY
Per Section 5.4 of NDRBCA Guidance document this pathway requires the (i) surface water classification, (ii) surface water quality criteria, and (iii) location of point of exposure (POE). Based on these acceptable RBTLs are developed for (i) groundwater POD, (ii) subsurface soil, and (iii) surface soil.
For this pathway provide the following:
	SURFACE WATER CLASSIFICATION		STREAM WATER QUALITY CRITERIA
		Class I streams		Aquatic life
		Class IA streams			Acute
		Class II streams			Chronic
		Class III streams		Human health
		Wetlands			Ingestion of aquatic organisms & drinking
		Lakes and reservoirs (Class 1 to 5)*			water for Class I, IA, and II
					Ingestion of aquatic organisms for Class III
	Location of POE for Tier 1:			ft
	(The distance from source to the point where groundwater seeps into the surface water)
	Location of POE for Tier 2:			ft
	(The distance from source to the downstream edge of the mixing zone within the surface water)
	Location of POD for Tier 2:			ft
	(The distance from source to the POD well)
	*: Note, lakes and reservoirs are subcategorized as Class 1 to Class 5 based on the type of fishery (e.g., cold water, warm water, etc.) the lake or reservoir can support (refer to Appendix I and Appendix II of NDAC 33.1-16-02.1).
	Note, there may be multiple PODs.
ADDITIONAL NOTES FOR CONSIDERATION OF SURFACE WATER PROTECTION PATHWAY
Attachments: (1): Figure 21: Figure showing the location(s) of the soil source(s), location of POE, and location(s) of POD for Surface Water Protection

C/ NC*

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FORM 15(1)

NDRBCA REPORT												FORM NO. 15 - ON-SITE RESIDENT (CURRENT CONDITIONS)
Facility ID number (if any):				Site address:
Date form completed:				Form completed by:
COMPARISON OF REPRESENTATIVE CONCENTRATIONS WITH TIER 1 RBSLs- ON-SITE RESIDENT (CURRENT CONDITIONS)
CHEMICALS OF CONCERN	SURFACE SOIL			SOIL VAPOR			GROUNDWATER
	Ingestion, dermal contact, outdoor inhalation of vapors and particulates		NC	Indoor inhalation of vapors		NC	Domestic use of water (ingestion of and dermal contact with, and inhalation of vapors due to indoor water use)		NC	Indoor inhalation of vapors		NC
	Rep.	SLs	E/NE	Rep.	SLs	E/NE	Rep.	SLs	E/NE	Rep.	SLs	E/NE
	Conc.			Conc.			Conc.			Conc.
	[mg/kg]	[mg/kg]		[mg/kg]	[mg/kg]		[µg/L]	[µg/L]		[µg/L]	[µg/L]
Benzene		1E+01	0		NA	0		5E+00	0		NA	0
Ethylbenzene		6E+01	0		NA	0		7E+02	0		NA	0
Isopropylbenzene (Cumene)		2E+03	0		NA	0		5E+02	0		NA	0
Methyl tert-Butyl Ether (MTBE)		5E+02	0		NA	0		1E+02	0		NA	0
Naphthalene		2.0E+01	0		NA	0		1.2E+00	0		NA	0
1,2,4-Trimethylbenzene		3.0E+02	0		NA	0		5.6E+01	0		NA	0
1,3,5-Trimethylbenzene		2.7E+02	0		NA	0		6.0E+01	0		NA	0
Toluene		4.9E+03	0		NA	0		1.0E+03	0		NA	0
Xylene (total)		5.8E+02	0		NA	0		1.0E+04	0		NA	0
Acenaphthene		3.6E+03	0		NA	0		5.3E+02	0		NA	0
Anthracene		1.8E+04	0		NA	0		1.8E+03	0		NA	0
Benzo(a)anthracene		1.1E+01	0		NA	0		3.0E-01	0		NA	0
Benzo (a) Pyrene		1.1E+00	0		NA	0		2.0E-01	0		NA	0
Benzo(b)fluoranthene		1.1E+01	0		NA	0		2.5E+00	0		NA	0
Benzo(k)fluoranthene		1.1E+02	0		NA	0		2.5E+01	0		NA	0
Chrysene		1.1E+03	0		NA	0		2.5E+02	0		NA	0
Ethylene dibromide		3.6E-01	0		NA	0		5.0E-02	0		NA	0
Fluoranthene		2.4E+03	0		NA	0		8.0E+02	0		NA	0
Fluorene		2.4E+03	0		NA	0		2.9E+02	0		NA	0
Indeno (1,2,3-cd) Pyrene		1.1E+01	0		NA	0		2.5E+00	0		NA	0
1-Methylnapthalene		1.8E+02	0		NA	0		1.1E+01	0		NA	0
2-Methylnapthalene		2.4E+02	0		NA	0		3.6E+01	0		NA	0
Naphthalene		2.0E+01	0		NA	0		1.2E+00	0		NA	0
Pyrene		1.8E+03	0		NA	0		1.2E+02	0		NA	0
Arsenic		6.8E+00	0		NA	0		1.0E+01	0		NA	0
Barium		1.5E+04	0		NA	0		2.0E+03	0		NA	0
Beryllium		1.6E+02	0		NA	0		4.0E+00	0		NA	0
Cadmium (diet)		7.1E+00	0		NA	0		NA	0		NA	0
Cadmium (water)		NA	0		NA	0		5.0E+00	0		NA	0
Chromium (III)		1.2E+05	0		NA	0		2.2E+04	0		NA	0
Chromium (VI)		3.0E+00	0		NA	0		3.5E-01	0		NA	0
Chromium (total)		NA	0		NA	0		1.0E+02	0		NA	0
Lead		4.0E+02	0		NA	0		1.5E+01	0		NA	0
Manganese (non-diet)		1.8E+03	0		NA	0		4.3E+02	0		NA	0
Mercury (elemental)		1.1E+01	0		NA	0		2.0E+00	0		NA	0
Selenium		3.9E+02	0		NA	0		5.0E+01	0		NA	0
Silver		3.9E+02	0		NA	0		9.4E+01	0		NA	0
Hexachloroethane		1.8E+01	0		NA	0		3.3E+00	0		NA	0
Pentachloroethane		7.7E+01	0		NA	0		6.5E+00	0		NA	0
1,1,1,2-Tetrachloroethane		2.0E+01	0		NA	0		5.7E+00	0		NA	0
1,1,2,2-Tetrachloroethane		6.0E+00	0		NA	0		7.6E-01	0		NA	0
1,1,2-Trichloroethane		1.1E+01	0		NA	0		5.0E+00	0		NA	0
1,1,1-Trichloroethane		8.1E+03	0		NA	0		2.0E+02	0		NA	0
1,2-Dichloroethane		4.6E+00	0		NA	0		5.0E+00	0		NA	0
1,1-Dichloroethane		3.6E+01	0		NA	0		2.8E+01	0		NA	0
Chloroethane		5.4E+03	0		NA	0		8.3E+03	0		NA	0
Perchloroethene (PCE)		2.4E+02	0		NA	0		5.0E+00	0		NA	0
Trichloroethene (TCE)		9.4E+00	0		NA	0		5.0E+00	0		NA	0
1,1-Dichloroethene		2.3E+02	0		NA	0		7.0E+00	0		NA	0
cis-1,2-Dichloroethene		1.6E+02	0		NA	0		7.0E+01	0		NA	0
trans-1,2-Dichloroethene		7.0E+01	0		NA	0		1.0E+02	0		NA	0
VinyL chloride (VC)		5.9E-01	0		NA	0		2.0E+00	0		NA	0
Bromide		NA	0		NA	0		NA	0		NA	0
Chloride		NA	0		NA	0		NA	0		NA	0
Nitrate as total nitrogen		1.3E+05	0		NA	0		1.0E+04	0		NA	0
Strontium		4.7E+04	0		NA	0		1.2E+04	0		NA	0
Notes:
E Representative concentration exceeds screening level (SL).
NE Representative concentration does not exceed SL.											Page 1 of
Attachments: (1) Attachment 8: Documentation for calculation of representative concentrations; (2) Attachment 9: Laboratory analytical report

&CPage &P of &N

E/NE

MAIN MENU

FORM 15(2)

NDRBCA REPORT									FORM NO. 15 - ON-SITE COMMERCIAL/INDUSTRIAL WORKER (CURRENT CONDITIONS)
Facility ID number (if any):				Site address:
Date form completed:				Form completed by:
COMPARISON OF REPRESENTATIVE CONCENTRATIONS WITH TIER 1 RBSLs- ON-SITE COMMERCIAL/INDUSTRIAL WORKER (CURRENT CONDITIONS)
CHEMICALS OF CONCERN	SURFACE SOIL			SOIL VAPOR			GROUNDWATER
	Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates		NC	Indoor inhalation of vapors		NC	Indoor inhalation of vapors		NC
	Rep.	SLs	E/NE	Rep.	SLs	E/NE	Rep.	SLs	E/NE
	Conc.			Conc.			Conc.
	[mg/kg]	[mg/kg]		[mg/kg]	[mg/kg]		[µg/L]	[µg/L]
Benzene		5E+01	0		NA	0		NA	0
Ethylbenzene		3E+02	0		NA	0		NA	0
Isopropylbenzene (Cumene)		1E+04	0		NA	0		NA	0
Methyl tert-Butyl Ether (MTBE)		2E+03	0		NA	0		NA	0
Naphthalene		8.6E+01	0		NA	0		NA	0
1,2,4-Trimethylbenzene		1.8E+03	0		NA	0		NA	0
1,3,5-Trimethylbenzene		1.5E+03	0		NA	0		NA	0
Toluene		4.7E+04	0		NA	0		NA	0
Xylene (total)		2.5E+03	0		NA	0		NA	0
Acenaphthene		4.5E+04	0		NA	0		NA	0
Anthracene		2.3E+05	0		NA	0		NA	0
Benzo(a)anthracene		2.1E+02	0		NA	0		NA	0
Benzo (a) Pyrene		2.1E+01	0		NA	0		NA	0
Benzo(b)fluoranthene		2.1E+02	0		NA	0		NA	0
Benzo(k)fluoranthene		2.1E+03	0		NA	0		NA	0
Chrysene		2.1E+04	0		NA	0		NA	0
Ethylene dibromide		1.6E+00	0		NA	0		NA	0
Fluoranthene		3.0E+04	0		NA	0		NA	0
Fluorene		3.0E+04	0		NA	0		NA	0
Indeno (1,2,3-cd) Pyrene		2.1E+02	0		NA	0		NA	0
1-Methylnapthalene		7.3E+02	0		NA	0		NA	0
2-Methylnapthalene		3.0E+03	0		NA	0		NA	0
Naphthalene		8.6E+01	0		NA	0		NA	0
Pyrene		2.3E+04	0		NA	0		NA	0
Arsenic		3.0E+01	0		NA	0		NA	0
Barium		2.2E+05	0		NA	0		NA	0
Beryllium		2.3E+03	0		NA	0		NA	0
Cadmium (diet)		1.0E+02	0		NA	0		NA	0
Cadmium (water)		NA	0		NA	0		NA	0
Chromium (III)		1.8E+06	0		NA	0		NA	0
Chromium (VI)		6.3E+01	0		NA	0		NA	0
Chromium (total)		NA	0		NA	0		NA	0
Lead		8.0E+02	0		NA	0		NA	0
Manganese (non-diet)		2.6E+04	0		NA	0		NA	0
Mercury (elemental)		4.6E+01	0		NA	0		NA	0
Selenium		5.8E+03	0		NA	0		NA	0
Silver		5.8E+03	0		NA	0		NA	0
Hexachloroethane		8.0E+01	0		NA	0		NA	0
Pentachloroethane		3.6E+02	0		NA	0		NA	0
1,1,1,2-Tetrachloroethane		8.8E+01	0		NA	0		NA	0
1,1,2,2-Tetrachloroethane		2.7E+01	0		NA	0		NA	0
1,1,2-Trichloroethane		5.0E+01	0		NA	0		NA	0
1,1,1-Trichloroethane		3.6E+04	0		NA	0		NA	0
1,2-Dichloroethane		2.0E+01	0		NA	0		NA	0
1,1-Dichloroethane		1.6E+02	0		NA	0		NA	0
Chloroethane		2.3E+04	0		NA	0		NA	0
Perchloroethene (PCE)		1.0E+03	0		NA	0		NA	0
Trichloroethene (TCE)		6.0E+01	0		NA	0		NA	0
1,1-Dichloroethene		1.0E+03	0		NA	0		NA	0
cis-1,2-Dichloroethene		2.3E+03	0		NA	0		NA	0
trans-1,2-Dichloroethene		3.0E+02	0		NA	0		NA	0
VinyL chloride (VC)		1.7E+01	0		NA	0		NA	0
Bromide		NA	0		NA	0		NA	0
Chloride		NA	0		NA	0		NA	0
Nitrate as total nitrogen		1.9E+06	0		NA	0		NA	0
Strontium		7.0E+05	0		NA	0		NA	0
Notes:
E Representative concentration exceeds screening level (SL).
NE Representative concentration does not exceed SL.								Page 2 of
Attachments: (1) Attachment 8: Documentation for calculation of representative concentrations; (2) Attachment 9: Laboratory analytical report

&CPage &P of &N

E/NE

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FORM 15(3)

NDRBCA REPORT			FORM NO. 15 - ON-SITE CONSTRUCTION WORKER (CURRENT CONDITIONS)
Facility ID number (if any):
Date form completed:
COMPARISON OF REPRESENTATIVE CONCENTRATIONS WITH TIER 1 RBSLs- ON-SITE CONSTRUCTION WORKER (CURRENT CONDITIONS)
CHEMICALS OF CONCERN	SURFACE SOIL
	Ingestion of and dermal contact with, and outdoor inhalation of vapors and particulates		NC
	Rep.	SLs	E/NE
	Conc.
	[mg/kg]	[mg/kg]
Benzene			0
Ethylbenzene			0
Isopropylbenzene (Cumene)			0
Methyl tert-Butyl Ether (MTBE)			0
Naphthalene			0
1,2,4-Trimethylbenzene			0
1,3,5-Trimethylbenzene			0
Toluene			0
Xylene (total)			0
Acenaphthene			0
Anthracene			0
Benzo(a)anthracene			0
Benzo (a) Pyrene			0
Benzo(b)fluoranthene			0
Benzo(k)fluoranthene			0
Chrysene			0
Ethylene dibromide			0
Fluoranthene			0
Fluorene			0
Indeno (1,2,3-cd) Pyrene			0
1-Methylnapthalene			0
2-Methylnapthalene			0
Naphthalene			0
Pyrene			0
Arsenic			0
Barium			0
Beryllium			0
Cadmium (diet)			0
Cadmium (water)			0
Chromium (III)			0
Chromium (VI)			0
Chromium (total)			0
Lead			0
Manganese (non-diet)			0
Mercury (elemental)			0
Selenium			0
Silver			0
Hexachloroethane			0
Pentachloroethane			0
1,1,1,2-Tetrachloroethane			0
1,1,2,2-Tetrachloroethane			0
1,1,2-Trichloroethane			0
1,1,1-Trichloroethane			0
1,2-Dichloroethane			0
1,1-Dichloroethane			0
Chloroethane			0
Perchloroethene (PCE)			0
Trichloroethene (TCE)			0
1,1-Dichloroethene			0
cis-1,2-Dichloroethene			0
trans-1,2-Dichloroethene			0
VinyL chloride (VC)			0
Bromide			0
Chloride			0
Nitrate as total nitrogen			0
Strontium			0
Notes:
E Representative concentration exceeds screening level (SL).
NE Representative concentration does not exceed SL.
Attachments: (1) Attachment 8: Documentation for calculation of representative concentrations; (2) Attachment 9: Laboratory analytical report

&CPage &P of &N

E/NE

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FORM 15(4)

NDRBCA REPORT

FORM NO. 15 - ON-SITE RESIDENT (FUTURE CONDITIONS)

Facility ID number (if any):

Site address:

Date form completed:

Form completed by:

COMPARISON OF REPRESENTATIVE CONCENTRATIONS WITH TIER 1 RBSLs- ON-SITE RESIDENT (REASONABLY ANTICIPATED FUTURE CONDITIONS)

CHEMICALS OF CONCERN

SURFACE SOIL

SOIL VAPOR

GROUNDWATER

Ingestion, dermal contact, outdoor inhalation of vapors and particulates

Indoor inhalation of vapors

Domestic use of water (ingestion, dermal contact, inhalation of vapors due to indoor water use)

Indoor inhalation of vapors

Rep.

SLs

E/NE

Rep.

SLs

E/NE

Rep.

SLs

E/NE

Rep.

SLs

E/NE

Conc.

[mg/kg]

[µg/L]

Benzene

1E+01

5E+00

Ethylbenzene

6E+01

7E+02

Isopropylbenzene (Cumene)

2E+03

5E+02

Methyl tert-Butyl Ether (MTBE)

5E+02

1E+02

Naphthalene

2.0E+01

1.2E+00

1,2,4-Trimethylbenzene

3.0E+02

5.6E+01

1,3,5-Trimethylbenzene

2.7E+02

6.0E+01

Toluene

4.9E+03

1.0E+03

Xylene (total)

5.8E+02

1.0E+04

Acenaphthene

3.6E+03

5.3E+02

Anthracene

1.8E+04

1.8E+03

Benzo(a)anthracene

1.1E+01

3.0E-01

Benzo (a) Pyrene

1.1E+00

2.0E-01

Benzo(b)fluoranthene

1.1E+01

2.5E+00

Benzo(k)fluoranthene

1.1E+02

2.5E+01

Chrysene

1.1E+03

2.5E+02

Ethylene dibromide

3.6E-01

5.0E-02

Fluoranthene

2.4E+03

8.0E+02

Fluorene

2.4E+03

2.9E+02

Indeno (1,2,3-cd) Pyrene

1.1E+01

2.5E+00

1-Methylnapthalene

1.8E+02

1.1E+01

2-Methylnapthalene

2.4E+02

3.6E+01

Naphthalene

2.0E+01

1.2E+00

Pyrene

1.8E+03

1.2E+02

Arsenic

6.8E+00

1.0E+01

Barium

1.5E+04

2.0E+03

Beryllium

1.6E+02

4.0E+00

Cadmium (diet)

7.1E+00

Cadmium (water)

5.0E+00

Chromium (III)

1.2E+05

2.2E+04

Chromium (VI)

3.0E+00

3.5E-01

Chromium (total)

1.0E+02

Lead

4.0E+02

1.5E+01

Manganese (non-diet)

1.8E+03

4.3E+02

Mercury (elemental)

1.1E+01

2.0E+00

Selenium

3.9E+02

5.0E+01

Silver

3.9E+02

9.4E+01

Hexachloroethane

1.8E+01

3.3E+00

Pentachloroethane

7.7E+01

6.5E+00

1,1,1,2-Tetrachloroethane

2.0E+01

5.7E+00

1,1,2,2-Tetrachloroethane

6.0E+00

7.6E-01

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Jul 16, 2025.