ࡱ> %` `qbjbjNN k,, ~~~~$PB 6!L;l!4(4(4(4()&9.51v:x:x:x:x:x:x:$<hg?,:3))33:~~4(4(M;6663.~R4(4(v:63v:668"F94(! 039 :lc;0;9,?{46?F9?F9202"63#3222::5j222;3333dDZ,~~~~~~   Maine Department of Environmental Protection Maine Voluntary Response Action Program Application for Assistance Please complete this application to request technical assistance from the Voluntary Remedial Action Plan Program (VRAP) pursuant to Title 38 MRSA, Section 342, Subsection 15. General Site Information Property name:  FORMTEXT       Street Address:  FORMTEXT       City (or Township):  FORMTEXT       Tax map #:  FORMTEXT       Lot #:  FORMTEXT       UTM Coordinates (Map Datum: NAD83):  FORMTEXT       Total Acreage of Property (all parcels):  FORMTEXT       Property Description Recorded at Registry of Deeds County:  FORMTEXT       Book:  FORMTEXT       Page:  FORMTEXT       Applicant Information Applicant/Organization*:  FORMTEXT       Contact Person:  FORMTEXT       Title:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       E-mail:  FORMTEXT       * The applicant/co-applicant are the individual(s) or organization(s) that will be the recipient of any applicable administrative or liability assurances provided by VRAP. The applicant is also responsible for payment of fees for Department review and oversight costs. Co-Applicant Information (if applicable) Co-Applicant/Organization*:  FORMTEXT       Contact Person:  FORMTEXT       Title:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       E-mail:  FORMTEXT       Co-Applicant/Organization*:  FORMTEXT       Contact Person:  FORMTEXT       Title:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       E-mail:  FORMTEXT       Current property owner (if different than applicant) Name:  FORMTEXT       Title:  FORMTEXT       Organization:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       E-mail:  FORMTEXT       Involvement with other regulatory programs  FORMCHECKBOX  Yes  FORMCHECKBOX  None known If yes, list the program/contact person from the Department:  FORMTEXT       Contact person(s) Please list the name(s) of your current environmental consultant and legal counsel. 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For  FORMTEXT       FORMTEXT      ,  FORMTEXT       of  FORMTEXT      . For  FORMTEXT       FORMTEXT      ,  FORMTEXT       of  FORMTEXT      . For  FORMTEXT       FORMTEXT      ,  FORMTEXT       of  FORMTEXT      . For  FORMTEXT       FORMTEXT      ,  FORMTEXT       of  FORMTEXT      . Certification I hereby make a request of VRAP to assist me and the company/organization I represent in determining whether the above-described property has been the site of a release or threatened release of a hazardous substance, hazardous waste, hazardous matter, special waste, pollutant or contaminant, including petroleum products or by-products. I understand this assistance may include the review of agency records and files, and review and approval of my investigation plans and reports as well as remedial action plans and implementation. I am aware that the property listed in this application will be placed on the Division of Remediation s Sites List Database that is located on the Department s website, and that any documents I submit to the Department are publicly available through their file room. I am also aware that VRAP, at its discretion, may contact municipal officials regarding investigation/ remedial actions at sites participating in the program. I am further aware that I must reimburse VRAP for the costs of providing this assistance. I understand that reimbursement requests may be made on a periodic basis and that failure to reimburse VRAP for costs in a timely manner may result in disqualification from VRAP and/or liens being placed on the property. Typed/printed name:  FORMTEXT       Title:  FORMTEXT       Signature:___________________________________________ Date:_______________ *****Note: For Properties with Petroleum Discharges from USTs or ASTs***** If your property has petroleum discharges (or potential discharges) related to an underground storage tank ( UST ) or aboveground storage tank ( AST ) facility, please also sign the following: I hereby agree to comply with Title 38 MRSA, Section 568 A.4, which includes the submittal of work plans, budgets, and schedules to the Department for review and approval. I also agree to keep a detailed record of all costs associated with the investigation and cleanup of petroleum discharges at the property, and will submit estimates of past costs to investigate and cleanup petroleum discharges at the property that have been incurred prior to making this application. Typed/printed name:  FORMTEXT       Title:  FORMTEXT       Signature:___________________________________________ Date:_______________ Revised : 4/17/08     (Z*Z,Z6Z8Z:ZHZJZLZ`ZbZdZnZpZrZtZ [ [[[[[,[.[0[:[ܾܠܴ|paWܠB(j4hbhbB*CJUphh^B*CJphh^h^5B*CJphh[5B*CJphh^h<5B*CJph(j3hbhbB*CJUphhbB*CJphh|LB*CJphh/mB*CJphheB*CJph'jhbB*CJUmHnHphujhbB*CJUph(j3hbhbB*CJUph:[>[R[T[V[`[b[f[h[j[l[[[[[[[[[[[[[[[[[[[[[[[[[\\k(j5hbhbB*CJUphh<B*CJph(jf5hbhbB*CJUph(j4hbhbB*CJUphh^B*CJph'jhbB*CJUmHnHphu(jz4hbhbB*CJUphhbB*CJphjhbB*CJUph$[[[\\\N]P]R]^^^^^^^c cvfxfhh d 7$8$H$  d 7$8$H$ !dh7$8$ !dh7$8$gd^\\\"\$\*\,\.\B\D\F\P\R\X\^\b\d\x\z\|\\\\\\\\\\\\\\\\\\\ܾܴܴܴܴܴuܴ`(j*8hbhbB*CJUph(j7hbhbB*CJUph(j>7hbhbB*CJUph(j6hbhbB*CJUphhbB*CJphh^B*CJph'jhbB*CJUmHnHphujhbB*CJUph(jR6hbhbB*CJUph%\\\\\\]]]]]]]] ]$]&]:]<]>]H]J]L]N]R]X]Z]\]p]r]t]~]]]]]]]]]]]ȳȞȉt(j:hbhbB*CJUph(j9hbhbB*CJUph(j9hbhbB*CJUph(j8hbhbB*CJUphhbB*CJphh^B*CJphjhbB*CJUph'jhbB*CJUmHnHphu)]]]]]]]]]]]]]]^ ^ ^^^^^^0^2^4^>^B^V^X^Z^d^f^l^n^p^^^^ܾܾܾܾܾuܴܾ`(jP<hbhbB*CJUph(j;hbhbB*CJUph(jd;hbhbB*CJUph(j:hbhbB*CJUphh^B*CJphhbB*CJph'jhbB*CJUmHnHphujhbB*CJUph(jx:hbhbB*CJUph%^^^^^^^^^^^^^^^^^^^"aac cee2e8eBeLeeeffff*g,gRhhhhiiҳȩyuqmuuuuqqqyh>rhFQh/mheB*CJphheB*CJRHfphheB*CJRHephheh[B*CJphh<B*CJph(j<hbhbB*CJUphh^B*CJphhbB*CJphjhbB*CJUph'jhbB*CJUmHnHphu*ii(i*i,i6i8iJiTiXiZinipiri|i~ijjjjjjjj:kkkl2l4l6lZlhljll񴛖}yqiqay]yYhOIhh>rh/m5hh5hh>r5h>rhlh/mhL3 hL35hL3hL35 h^5he(j=hbhbB*CJUphheB*CJph'jhbB*CJUmHnHphu(j<=hbhbB*CJUphhbB*CJphjhbB*CJUph"hiijjjjj6l8loo~pppqq>qBqDqHq  !dh7$8$ gd>rd 7$8$H$gd>r $ a$gdL3 d 7$8$H$ d 7$8$H$gdblllPnooppp,p.p0p:pq@qDqFqJqLqPqRqVqXq\qѨѨ|xplplplplhlhKthfjhfUhh[heh>rh>rB*CJaJph(j>hbhbB*CJUph'jhbB*CJUmHnHphu(j(>hbhbB*CJUphjhbB*CJUphhbB*CJphh>rB*CJphhlhOIh>r(HqJqNqPqTqVqXqZq\q^q`q  !dh7$8$ \q^q`qhehq5 0&P:p</ =!"#$% 2&P:p</ =!"#$% `Dd9WYllX  c 4ADEPLogobV͂r\G`DnV͂r\G`PNG  IHDR9ÅPLTE1c/!bKGDH%IDATx휍 ӝ= HܭՎx1?Qٱ;_k9=Ck9=Ck9rǏ΂p莛PE?v9꽅!POD.;XreHnwmȡwC "<:G%U YltrFB&EV[AL83RU!7.x[yc~ٺ>=v}Yĝ0wp0Di|N{+aKC&Mfݫ29(QnbO*7]M+Хsii-&I]]FrtqZpw(06t lrr5+![mNq`ftp#\ NN)Cw}t4.BS56srQrGktA䉟Zg4-N~Z INM2&S`jS 򟘙 Un7,bXcUp7Ɯ:D 691p;pc(ݔX2a{{(Cv Fu̘MHV;EH(/3k]L~;qS&n"qC#8E鴫ORt2RB18{Wr@:fh q6! 錴rAa=rvum#A#)w].OՂo =qQa8pWq]VV\'کk~yVKn (I`S4L'wy, /W>j$s@Bqz'$d]tClLx +llҜ9O 0ty[@f!Z'nǼ]WKbPtFrٔʛ].ݮZr}&h%]uKed͒(PΫCcRMz| r(ZrrEKÒ+VzVrr nb+hm=p.@~δˎT0+lȧݔҮo.b#WVd]Wȵ\Qj]tѷK>Ɠkaf 6GNRdۺJ! 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