ࡱ> OQLMN#` bjbjmm C,+*444HvvvvTwHzFbbbbA@dQSSSSSS$`hȨ`w4َ=Aََwbbd%%%َ(8b4bQ%َQ%%4%bz +]v%M z0%((%(4%(Z@%34grwwََََHHH8 >8HHH >HHH Sand and Salt Storage Area Registration Form and Request for Variance (pursuant to 06 CMR Ch. 574)Sand and Salt Pile Program Dept. of Environmental Protection 17 State House Station Augusta, ME 04333-0017 Telephone: (207)287-3901 Instructions: Please complete Sections 1 through 3 for each sand and salt storage area that you are now registering. Use a separate form for each storage area. If you are applying for a variance from either the siting or operational requirements of DEP Rules Chapter 574, Siting and Operation of Road Salt and Sand-Salt Storage Areas, you must complete Sections 1 through 3 and provide additional information in Section 4 and/or Section 5. Purpose Please check one. FORMCHECKBOX This registration form is for a proposed sand and salt storage area. No material is stored on the site at this time. FORMCHECKBOX This registration form is for an existing sand and salt storage area not previously registered with the DEP. Material has been stored on this site since FORMTEXT      (year). FORMCHECKBOX This registration form is for an existing site registered with the DEP. I am now applying for a variance from the siting and/or operations requirements. Section 1: Sand and Salt Storage Area Location and Contact InformationTown: FORMTEXT      County: FORMTEXT      Provide or describe the physical location of the sand and salt storage area (i.e., Emergency 911 address) FORMTEXT  Please provide a map (hand-drawn, DeLorme, USGS Topo or DEP-provided) indicating the storage location.Latitude and Longitude coordinates or UTM coordinates if available Contact Person for Sand and Salt Storage Area Contact Name: FORMTEXT      Title: FORMTEXT      Business Name: FORMTEXT      Mailing Address: FORMTEXT      Contact s Daytime Telephone: FORMTEXT      E-mail: FORMTEXT       Please indicate(X, " or name) who owns each of the following elements of the sand and salt storage location: Who owns the sand?Who owns the salt?Who owns the land on which the storage is located?Person or Company, listed above FORMTEXT       FORMTEXT       FORMTEXT      Town or County Government FORMTEXT       FORMTEXT       FORMTEXT      Other (please specify) FORMTEXT       FORMTEXT       FORMTEXT       Did you register a sand and salt pile storage area with the Department of Environmental Protection in 1986 or1999? FORMCHECKBOX Yes, different site FORMCHECKBOX Yes, same site FORMCHECKBOX No FORMCHECKBOX Dont know If Yes, different site: Please provide the location of the previous storage site: FORMTEXT   Are you still storing sand/salt material at the previously registered site: FORMCHECKBOX Yes FORMCHECKBOX No Section 2: Siting Elements  FORMCHECKBOX Check this box if you are applying for a variance from one or more of the siting requirements listed in DEP Rules, Chapter 574, Section 3(B) and provide the additional information in Section 4 of this form. Is the area in which the sand and salt pile is located served by a public water supply: FORMCHECKBOX Yes FORMCHECKBOX No If, No, how far (in feet) is the nearest drinking water well from the sand and salt pile? FORMTEXT      feetFor existing sites only: Have you ever received complaints from nearby well owners about salty-tasting water? FORMCHECKBOX Yes FORMCHECKBOX No Is the sand and salt pile located on a significant sand and gravel aquifer (mapped by the Maine Geological Survey? FORMCHECKBOX Yes FORMCHECKBOX No Is the sand and salt pile located in a source water protection area (SWPA) for a public water supply: FORMCHECKBOX Yes FORMCHECKBOX No Section 3: Operational Elements  FORMCHECKBOX Check this box if you are applying for a variance from one or more of the operational requirements Listed in DEP Rules, Chapter 574, Section 4 and provide the additional information in Section 5 of this form. Please provide the amount of material to be stored on site: Unmixed Salt (tons)Mixed Sand and Salt(cubic yards)Liquid Chloride Product (gallons) FORMTEXT       FORMTEXT       FORMTEXT      Salt and sand-salt materials are/will be stored: (check all that apply) FORMCHECKBOX In a building FORMCHECKBOX On a padDate (or anticipated date) of building construction:Date (or anticipated date) of pad construction: FORMTEXT       FORMTEXT      Dimensions of building:Dimensions of pad: FORMTEXT       FORMTEXT      Type/style of building:  FORMTEXT      Covering material to be used:  FORMTEXT       Where (location) is the sand mixed with the salt? FORMTEXT       Do you have an operations and maintenance plan for your storage area? FORMCHECKBOX Yes FORMCHECKBOX No For existing storage areas; Is there tree or other vegetation damage from salt apparent at this site? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe the extent of damage: FORMTEXT   Notes/Comments: FORMTEXT  Completed by: FORMTEXT      Date FORMTEXT       Section 4: Application for Variance from Siting Requirements Instructions: Please answer the following questions to the best of your ability. Attach additional pages, if needed. You may be contacted for additional information once your application is received.Application for variance from siting requirements in DEP Rules, Chapter 574 to allow siting of a sand and salt storage area: (check all that apply) FORMCHECKBOX On a significant sand and gravel aquifer FORMCHECKBOX In a source water protection area of a public water supply FORMCHECKBOX Within 300 feet of a private well Is the sand and salt pile located in an are legally zoned by the municipality for commercial, industrial or similar use? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Town does not have zoning. Is it likely that new houses (with wells) will be built within the next five years? FORMCHECKBOX Yes FORMCHECKBOX No Is the ground water in the area used for purposes other than drinking water (such as for industrial purposes, livestock management, agricultural irrigation)? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes: Please list other uses of ground water: FORMTEXT   What is the name of the nearest surface water body (stream, river, lake, ocean)? FORMTEXT      Distance to nearest surface water body FORMTEXT      FeetAre there feasible alternative sites to the proposed/current sand and salt storage area? FORMCHECKBOX Yes FORMCHECKBOX NoIf No: What constraints (economic, operational, environmental, etc.) are there preventing the use of an alternative location? Attach additional sheets, as needed.  FORMTEXT    If your are requesting a variance to allow siting within 300 feet of a private well, please provide the names and addresses of all well owners within 300 feet of the proposed/current storage location and the distance to their wellheads from the sand and salt pile/building.  FORMTEXT   If you are requesting a variance to allow siting within a source water protection area, please provide the name and address of the public water supplier in whose source water protection area the proposed/current sand/salt storage area lies.  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Attach additional sheets, as needed. You may be contacted for additional information once your application is received.Application for variance from operational requirements in DEP Rules, Chapter 574 to allow sand and salt storage: (check all that apply) FORMCHECKBOX Without a pad or FORMCHECKBOX with a pad other than specified in 06 CMR Chapter 574, Section 4(A) FORMCHECKBOX Without a cover or FORMCHECKBOX with a cover other than specified in 06 CMR Chapter 574, Section 4 (C) FORMCHECKBOX Other variance request: please be specific FORMTEXT       Is the sand and salt pile located in an area legally zoned by the municipality for commercial, industrial or similaruse? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Town does not have zoning Is it likely that new houses (with wells) will be built in the area within the next 5 years? FORMCHECKBOX Yes FORMCHECKBOX No Is the ground water in the area used for purposes other than drinking water (such as for industrial purposes, Livestock management, agricultural irrigation)? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes: Please list other uses of ground water:  FORMTEXT   What is the name of the nearest surface water body (stream, river, lake, ocean)? FORMTEXT      Distance to the nearest surface water body FORMTEXT      FeetWill this be a temporary site? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes: How long do you expect storage on site? FORMTEXT      Why is a temporary site needed? FORMTEXT   Where does stormwater or runoff from the storage area go? (be specific)  FORMTEXT      Is there a means or system to collect or treat stormwater from the sand and salt storage location? FORMCHECKBOX Yes FORMCHECKBOX No:If Yes: Please describe. Attach a diagram, if needed  FORMTEXT   Is there an existing Storm Water Pollution Prevention Plan for this site? FORMCHECKBOX Yes FORMCHECKBOX No If Yes: Attach planIs there an existing MEPDES/NPDES Stormwater Permit for the site? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes: What is the Permit ID# FORMTEXT       On a separate sheet of paper: Please explain what special characteristics of your site or operation (including best management practices) exist that support your request for a variance.  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