Compliance Period

Transcription

1 Waiver Application for Synthetic Organic Chemicals (SOC) Monitoring Compliance Period Rhode Island Department of HEALTH Division of Environmental Health Office of Drinking Water Quality

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3 Waiver Application for SOC Monitoring Introduction The cost of monitoring for all regulated Synthetic Organic Chemicals (SOCs) is approximately $625 per well per monitoring period (April 2015 cost estimate). This application allows a Groundwater Public Water System serving 3300 people or fewer to apply for a waiver from monitoring for SOCs during this three year compliance period, You might qualify for a waiver from monitoring for certain SOCs, if there have been no land uses in your wellhead protection area (WHPA) associated with the use of those chemicals during the last ten years and there have been no detections of those SOCs during previous monitoring. This waiver application contains the following components that you must complete. Please check the Completed? box in the table below as you prepare your application. Application Component Description Page Completed? 1. System Information Information about your public water system Certification Statements 3. Windshield Survey Using Paper Map Table 1. Land Uses Table 2. Details of Land Uses 4. Online Map 5. Submersible Pump Information Activity Use Surveys A statement that you must sign, certifying that all information provided is complete and accurate and a statement about SOC contamination or use within your WHPA A survey of land uses and activities in your WHPA, using the map included at the back of this application A table listing land uses that could potentially contribute SOCs A table to be completed based upon your survey of the WHPA Instructions for accessing a map of your WHPA online Details about submersible pump components used Optional but recommended surveys of land owners about properties with land uses that can potentially contribute SOCs Template In Appendix 1

4 Waiver Application for SOC Monitoring What If I Have Additional Questions? This application contains a Frequently Asked Questions section on page 15, as well as an Appendix for further information. If you have additional questions, please contact: Amy Parmenter, Rhode Island Department of HEALTH, Office of Drinking Water Quality Amy.Parmenter@health.ri.gov There also will be small group work sessions offered in the summer of 2015 by our program partners at the University of RI. If you are interested in participating, please contact Amy Parmenter for details. Do I Need More Than One Application? If your public water system uses only one well (one groundwater source), you only need to complete one application. However, if your public water system uses two or more wells and they are located in separate wellhead protection areas (WHPAs), you will need to complete an application for each WHPA. This application (without WHPA map) is available at: waiver/ What Is The Deadline For Submitting This Application and Where Do I Send It? The deadline is September 10, Please mail this completed application to: SOC Waiver Review Manager RI Department of HEALTH Three Capitol Hill, Room 209 Providence, RI

5 Waiver Application for SOC Monitoring System Information Public Water System (PWS) General Information PWS Name PWS ID Number PWS Owner s Name PWS Owner s Address PWS Owner s Phone/E mail PWS Operator s Name PWS Operator s Address PWS Operator s Phone/E mail Well Information Well Name (example: Booker Street Well) Well ID Number (example: WL001) Purpose (primary, secondary, emergency) Well Pump Brand and Year Well Pump Size (example: 10 gpm) Has the well pump been replaced in the last 10 years?** **If yes, please indicate whether the pump size is different from its replacement. 3

6 Waiver Application for SOC Monitoring Certification Statements Application Preparer s Information (If Someone Other Than Owner or Operator) Preparer s Name Preparer s Address Preparer s City, State Zip Preparer s Phone Preparer s E mail Owner/Operator Certification of Accuracy I certify that I have reviewed the information in this application. To the best of my knowledge and belief, the information in this application is complete and accurate. Signature of Owner or Operator Date Owner/Operator Certification of Known SOC Detections and SOC Usage Do you know of any Synthetic Organic Chemical (SOC) contaminations within your wellhead protection area (WHPA)? No Yes (If so, please explain.) Have you used or do you store any Synthetic Organic Chemicals (SOCs) within your wellhead protection area (WHPA)? No Yes (If so, please explain.) 4

7 Waiver Application for SOC Monitoring Windshield Survey of Land Uses and Activities Using the Paper Map of Your Wellhead Protection Area A map of your wellhead protection area (WHPA) has been attached to the end of this application. This map shows the boundaries of your WHPA and agricultural lands (diagonal lines) using a 2014 aerial photo. It will be necessary to use the map, as you conduct a windshield survey of the WHPA, noting land uses as you drive throughout the area and marking their locations on the map. Afterward, you will use the map to complete a table about land uses and activities. Steps To Conducting the Windshield Survey The following steps are offered as a guide for your windshield survey: Before You Go 1. Become familiar with Table 1. Land Uses In Your Wellhead Protection Area on pages Become familiar with the land uses described in the previous Waiver Application Notes, included in the Appendix of this application. The Notes offer historical information about which land uses have been found in your WHPA and will be important for determining changes in land uses over time. Please note when filling out the Table of Land Uses that you are being asked not only about current land uses but also about land uses during the past 10 years. 3. Become familiar with the map of your WHPA, attached to the end of the application. 4. Get ready for a drive around your WHPA. Having a driver and an observer/note taker will be much easier (and safer). 5. Bring a camera, in case there is a utility substation transformer. You will need to take a photo of the name plate. 6. Bring copies of the following so that you can mark them up in the field with notes but prepare a final version using this application: o WHPA map attached to the back of this application o Table 1. Land Uses In Your Wellhead Protection Area (WHPA) o Table 2. Details of Land Uses In Your Wellhead Protection Area (WHPA) On Your Drive 7. As you drive around your WHPA, look for any land uses listed in Table 1. For each land use present: 8. Circle yes on Table Mark its location on the map and label it with a number. 10. Fill in a line on Table 2, referencing that number and the land use or activity. Back At Home 11. Transfer the information from your copy of Table 1 into the table in this application. 12. Transfer the information from your copy of Table 2 into the table in this application, completing any details that you did not complete during the drive. 13. Be sure to include the map, with land uses marked, in this application when you return it. 5

8 Waiver Application for SOC Monitoring Other Sources of Information About Land Use Activities Your Source Water Assessment Report also might be helpful when considering activities within your WHPA. Most reports can be found at: Online aerial photographs can be used to supplement the paper map of your WHPA. This is particularly useful for getting a closer view of areas that are inaccessible by public roads. See instructions for accessing online maps in Section 4. How Can I Determine Whether SOCs Have Been Used? If you find any land uses within your WHPA that are included in Table 1 Land Uses In Your Wellhead Protection Area, the Department of HEALTH recommends contacting the owner of that property to determine whether or not any SOCs have been used, stored, transported, or disposed of there. Without that information, the Department of HEALTH will have to assume that there is a risk of SOC contamination, based on the presence of that land use. To assist you, an Activity Use Survey template and instructions have been provided in the Appendix of this application. A special note about roadways: The RI Department of Transportation has verified that they use only Glyphosate (for which there is currently a statewide waiver) on state roads. If there are town roads within your WHPA, you will need to verify with the local municipality s Department of Public Works whether SOCs have been used on the roads, and if so, which SOCs. They most likely will provide you with trade names of the herbicides and pesticides used, which you can look up in the table in the Appendix, Regulated Pesticides, Common Trade Names, and Related Chemicals, to determine if it contains SOCs. Beyond Land Use Activities Most land uses have the potential to contribute some synthetic organic chemicals (SOCs) to the environment. The land uses listed in Table 1 pose some of the greatest risks of SOC contamination to local waters, including drinking water supplies. However, the absence of a land use mentioned in that table does not imply that SOC contamination is not a risk. Waivers from monitoring will consider information presented in the table, but that information will not be the only criteria with which a decision is made. The results of previous monitoring, as well as known land uses or contamination in neighboring wellhead protection areas, will be included in the final decision. In addition, the contaminant Di(2 ethylhexyl)phthalate (DEHP) can come from components within the well, such as the torque arrestor, as well as from land use activities. Monitoring for DEHP may be required for all wells. 6

9 Waiver Application for SOC Monitoring Table 1. Land Uses In Your Wellhead Protection Area (WHPA) Land Use Activities AGRICULTURE fruit crops/orchards and vineyards/vegetable crops (including nuts, potatoes, onions, legumes, grasses, and cotton) Present Within Previous 10 Years? Yes No grains (excluding hay) Yes No Potential SOCs Contributed Alachlor; Aldicarb, Aldicarb Sulfoxide, Aldicarb Sulfone; Atrazine; Carbofuran; Chlordane; 2,4 D; Dalapon; Dinoseb; Dibromochloropropane (DBCP); Endrin; Ethylene Dibromide(EDB); Heptachlor; Heptachlor Epoxide; Lindane; Methoxychlor; Oxamyl; Picloram; Simazine; Toxaphene Aldicarb, Aldicarb Sulfoxide, Aldicarb Sulfone; Endrin; Atrazine; Carbofuran; Endrin; Ethylene Dibromide (EDB); Picloram turf Yes No 2,4 D; Atrazine; Carbofuran; Simazine Christmas tree farms Yes No Atrazine; Carbofuran; Lindane; Methoxychlor; Simazine nurseries/garden centers/ ornamentals/flowers Yes No Alachlor; Carbofuran; Dibromochloropropane (DBCP); Endrin; Lindane; Oxamyl; Methoxychlor; Simazine fish hatcheries or ponds Yes No Simazine livestock* or poultry Yes No Lindane; Methoxychlor; Toxaphene greenhouses Yes No Methoxychlor; Oxamyl *cattle, pigs, goats, sheep, horses INDUSTRIAL chemical factories; industrial facilities; manufacturing Yes No food and beverage production Yes No lumber yards/wood preserving factories Yes No meat packaging Yes No cosmetics industries Yes No mill site, former use or urban fill, where coal was used/ash deposited Di(2 ethylhexyl)adipate; Di(2 ethylhexyl)phthalates; Hexachlorocyclopentadiene; Ethylene Dibromide (EDB); Benzo(a)pyrene; Polychlorinated Biphenyls (PCBs); Hexachlorobenzene; Hexachlorocyclopentadiene; Heptachlor; Heptachlor epoxide those from chemical/industrial/manufacturing as well as Di(2 ethylhexyl)phthalates those from chemical/industrial/manufacturing as well as Lindane; Methoxychlor; Pentachlorophenol those from chemical/industrial/manufacturing as well as Di(2 ethylhexyl)adipate those from chemical/industrial/manufacturing as well as Di(2 ethylhexyl)adipate Yes No Benzo(a)pyrene 7

10 Waiver Application for SOC Monitoring COMMERCIAL veterinarians/pet groomers Yes No Lindane lumber yards or areas of wood storage Yes No Lindane; Methoxychlor; Pentachlorophenol; Hexachlorobenzene pest control businesses Yes No Chlordane; Endrin; Heptachlor; Heptachlor epoxide businesses selling pesticides or herbicides (e.g. general retail, feed stores, big box stores, etc.) Yes No Trade names of products for sale will vary from chemical names. auto repair; autobody; garages Yes No Di(2 ethylhexyl)adipate; Polychlorinated Biphenyls (PCBs) MUNICIPAL/GOVERNMENTAL landfills/hazardous waste facilities Yes No athletic fields Yes No 2,4 D Polychlorinated Biphenyls (PCBs); Heptachlor; Benzo(a)pyrene; Chlordane retention/detention basins Yes No 2,4 D; Dalapon; Ethylene Dibromide (EDB); Picloram military bases or operations Yes No 2,4,5 TP UTILITIES/TRANSPORTATION railways Yes No Picloram power (substation) transformers Yes* No Chlordane; Heptachlor; Heptachlor epoxide; Polychlorinated Biphenyls (PCBs) airports Yes No Di(2 ethylhexyl)adipate; Ethylene Dibromide (EDB) Town roadways/rights of way Yes No 2,4 D; Dalapon; Picloram auto repair; auto body; garages Yes No Di(2 ethylhexyl)adipate; Polychlorinated Biphenyls (PCBs) RECREATION golf courses Yes No 2,4 D *Please complete the section about substation transformers on page 9. 8

11 Waiver Application for SOC Monitoring Table 2. Details of Land Uses In Your Wellhead Protection Area (WHPA) For each land use activity marked yes in the previous table, please complete one line of the table below. Number You Labelled The Land Use On The Map(s) Land Use Activity Marked Yes (example: fruit crops) Name of Land Use Activity (example: potato farm; Farmer Bee s nursery; Bob s Auto Shop) Current or Not Current, But Within The Last 10 Years? Additional Information About Utility Substation Transformers This section must be completed if there is a utility substation transformer within your WHPA. Some older utility substation transformers may contain Polychlorinated Biphenyls (PCBs or Araclors). We can attempt to determine whether or not a substation transformer contains PCBs from the brand and date. There is usually a name plate located directly on the transformer, which you can use to complete the information below. If there is no name plate present, your local utility company might be able to provide this information. Please provide the information below as well as a photo of the name plate or written documentation from the utility company. Photo or Written Documentation? Brand Year 9

12 Waiver Application for SOC Monitoring Online Mapping of Regulated Facilities in Your Wellhead Protection Area In addition to considering land use activities that are obvious from a windshield survey, it is necessary to identify whether any facilities regulated by the Rhode Island Department of Environmental Management (RIDEM) exist within the WHPA that could be potential sources of contamination. This section describes how to locate these sites using the RIDEM Environmental Resource Map and how to report results. This online map is user friendly and does not require specialized computer skills. Depending upon the type of facilities in your area, you might be required to contact RIDEM for more information, and if necessary, schedule a file review. 1. Access the DEM Environmental Resource Map Open a web browser, go to and click onto Environmental Resource Map. The following map appears. Features we ll be using are highlighted. 10

13 Waiver Application for SOC Monitoring Find your location Using the search bar at top right, enter a street address or place within your WHPA. 3. Navigation basics Use the tool bar at the top left corner within the map to zoom in (+) or out ( ) of the view. As you change your zoom level (map scale), notice that the labeling of features changes. To pan (move the map in any direction), click on the map and holding the mouse button down, drag the cursor. The map will move. For more information about using the DEM map to explore your WHPA, including saving the map, please consult the instructions on: waiver/ 4. Find your WHPA Click on the Content button, the middle icon at top left of the map, to display a list of the layers in the map. If the content button is not visible, click onto Details. Click the Ground Water Resources group name to display all contents. Check the box at the left of the name to enable mapping. Check the boxes at CWHPA and NCWHPA to display the layers. Click the layer names to show the map symbol. Are you looking at your WHPA? If you re unsure, view the Aerial Photo as described below and compare with your paper map. 5. View Aerial Photo (Not required but helpful for completing the Windshield Survey) At the bottom of the Contents list, click on the box for Aerial Photo Use the online Aerial Photo to get a better view of land uses in your WHPA. Zoom in or out for a closer view as needed. Examine areas that are inaccessible by public roads. Try to identify land uses and activities based on land patterns and your knowledge of the area. In particular, look for activities that may be source of SOCs, such as agriculture, material/equipment storage, and dumps. Historical land uses may be examined using older aerial photos at the Topo Map & Aerial Photo Viewer 11

14 Waiver Application for SOC Monitoring Locate Regulated Facilities with a Greater Risk of SOCs. Regulated facilities are a potential source of SOCs and other pollutants that are either regulated by RIDEM or where a RIDEM investigation has been conducted and a file record exists. Some types are required to monitor for SOCs. All locations are approximate and may require verification through a DEM file review. Descriptions of the regulated facility types are in the Appendix. Click the RIDEM Regulated Facilities group name in the Contents list to show all layers under this heading. Check the box at left of the name to enable mapping. Check the box and the layer name of the layers shown below: 7. Are there any of the above regulated facilities in the WHPA? Review results for your WHPA and check the appropriate box below. If none of the above facilities are located in your WHPA, you re finished with this section. NO Based on review of your application by RI Health staff, you may be required to contact RIDEM for information about other regulated facilities or unmapped sites. YES If any of these sites are located in your WHPA you must complete the following steps: 12

15 Waiver Application for SOC Monitoring Identify each facility On the map, use your mouse to left click onto the map symbol for the facility. A pop up box will appear with details about the site. Use the following table to report details, using a separate row for each facility located in your WHPA. Type of Facility (CERCLIS or RIDEM Site Investigation and Remediation) SiteName or Registry ID SiteType or Primary Name State ID or location and address ProjCode or FIPS Code Date (if any) 9. Contact RIDEM for more information Contact the RIDEM Office of Waste Management at (401) or margaret.bradley@dem.ri.gov Explain that you are seeking information about SOCs regulated by DEM Remediation Regulations: Benzo(a)pyrene, Chlordane, Heptachlor and Polychlorinated biphenyls (PCBs) (Aroclors) and any others listed in the Regulated SOCs Appendix. Provide them with the information about each site listed in the above table and ask if there is sufficient information about each site to warrant a file review of these sites, other facilities within the WHPA, and unmapped sites. Note: A file review is likely to be required for a RIDEM Site Investigation & Remediation site. If the Waste Management staff recommends a file review ask for their guidance on what to look for specifically. The Office of Waste Management will collect the files for the review. Schedule the file review with the RIDEM Office of Technical and Customer Assistance (OCTA) as described at Summarize your communications with DEM and results of the file review and include with this application, with a copy to the DEM Office of Waste Management. 13

16 Waiver Application for SOC Monitoring Additional Information About Submersible Pumps Some submersible pump torque arresters can abrade against the wall of the well and release Di(2 ethylhexyl)phthalate (DEHP) into the drinking water. Which type of torque arrester was used in the well? Please provide documentation.* Natural Rubber Extruded PVC Unknown Electrical tape used to secure pump components in the well can release Di(2 ethylhexyl)phthalate (DEHP) into the drinking water. What was used in the well to secure the pump power cable and other components? Please provide documentation.* Electrical Tape Non metallic wire ties Other (explain: ) *Currently, waivers cannot be granted for DEHP. However, documented information will help determine whether waivers can be granted in the future. 14

17 Waiver Application for SOC Monitoring Frequently Asked Questions Can you help me understand more about Synthetic Organic Chemicals (SOCs) and why we are required to monitor for them, if we don t have a waiver? Synthetic Organic Chemicals (SOCs) are used as pesticides, insecticides, herbicides, fuel additives, and as other ingredients in manufacturing and industrial processes. They are generally toxic and can have significant health impacts; many are known carcinogens. The Environmental Protection Agency (EPA) amended the Safe Drinking Water Act in 1986 to require the periodic monitoring of regulated SOCs. Because some SOCs are not used in certain areas, the EPA has given state drinking water programs the option of waiving monitoring for certain SOCs. All groundwater public water systems in Rhode Island, serving 3300 persons or fewer, are eligible to apply for monitoring waivers. Each waiver lasts for that three year compliance period. How much would it cost to skip the waiver application and monitor for SOCs? The total cost of monitoring depends upon several factors: how many wells you need to monitor; the frequency of required monitoring; previous sampling history; and the lab you choose. If you would like to compare the cost of completing this application to the cost of monitoring during this compliance period, the Department of HEALTH can help you determine your specific requirements for sampling. As of April 2015, the average cost of testing one well for all SOCs is approximately $625 per monitoring period. So if you had only one well to monitor and needed to sample one time during this three year compliance period, your total monitoring cost would be approximately $625. If you had one well and needed to sample quarterly for the first year, your total cost would be $2500. The Department of HEALTH used to complete the waiver form for us. Why are we now expected to do it ourselves? The Department of HEALTH started conducting waiver reviews for small groundwater public water systems in the 1990s, and we repeated them every three (3) years. However, we found that many public water systems did not fully understand the process whereby waivers were granted or denied. In order to increase public water system involvement in this process, we have designed this new waiver application. Do water systems receive any automatic waivers? Yes, statewide waivers have been issued for: Dioxin; Diquat; Endothall; and Glyphosate. How quickly will the Department of HEALTH make a determination about the waiver that I am requesting? Because it takes time for the water system to complete the application and for staff at the Department of HEALTH to review the applications, we ask that they be submitted a few months prior to the monitoring deadline. We will render a decision as quickly as possible, while giving you enough time to sample, in the event that a waiver is denied. 15

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19 Appendix Regulated SOCs: Pesticides, Common Trade Names, and Related Chemicals Table Description of RIDEM Regulated Facilities Activity Use Survey (instructions, factsheet, survey template) Previous Waiver Notes Paper Map of WHPA

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21 Regulated SOCs: Pesticides, Common Trade Names, and Related Chemicals Chemical Name Trade Name Usage Alachlor Aldicarb, Aldicarb Sulfoxide, and Aldicarb Sulfone Lasso, Pillarzo, Alatox 480, Alazine, ALA, Lozo, Lariat, Marksman, Freedom, Micro Tech, Nudor Extra, Bronco, Alanex, Bullet, Stake, Shroud Temik, UC21149 Herbicide on corn, soybeans, dry beans, and sunflowers Threat to drinking water through runoff Many formulations Cancelled Restricted Use Pesticide (RUP)*** Insecticide for crops, particularly potatoes but also grain, peanuts, soybeans, and sugar beet. All products and uses banned in Rhode Island Atrazine** Benzo(a)pyrene Carbofuran Chlordane 2,4 D** Aatrex, Aktikon, Atrazinax, Atratol, Fenamin, Aatrex, Prozine, Gesaprim, Zeaphos, Nudor Extra, Atramet Combi, Crisazin Crisatrina, Kombi, Drexel, Rhino, Farmco Anizine, Aaa Flowable, Marksman, Primextra, Bicep, Conquest, Candex, Extrazine, Vestal, Rapuzin, Pramatol, Surpass, Bullet, Buctril, Laddock No trade name, a polyaromatic hydrocarbon, combustion byproduct Bay 70143, Crisfuran, Curaterr, Yaltox, Furadan, Carbodan, Carbosip, Chinufur, Kenofuran, Niagara Forchlor, Kill Ko, Sydane, Belt, Chlor Kil, Chlorotox, Corodane, Gold Crest C 100, Kilex Lindane, Kypchlo, Octachlor, Synklor, Termided, Topiclor 20, Velsicol 1068, Aspon chlordate, Ortho Klor, Niran, Termide, Chlorohepton 2,4 Dichlorophenoxy acetic acid, Acme Main 4, Acme Butyl Ester 4, Acme LV 4, Acme LV 6, Agrotect, Amoxone, Aquakleen, Chlorozxone, Croprider, Crossbow, D50, Dinoxol, DMA 4, Dormone, Emulsamine BK, Emulsamine E 3, Estone, Fernesta, Fernimine, Fernoxone, Ferxone, Lawn Keep, Macondray, Pennamine D, Planotox, Plantgard, Tributon, Weed B Gon, Weedar, Weedone, Weedmaster, Weed & Feed, Weedatul, Chipco Turf Herbicide D, DMA 4, Esterone 99, Formula 40, Spritz Hormit, 2,4 D, Weed Ag Bar, Weedez Wonder Bar, Basagran, Acme Super Brush Killer 875, U 46 DP, Duplosan DP D, Duplasan KV Combi, Chipco Turf Kleen, 2 Plus 2, Actril DS, Mad, Gordon s Vegemec Vegetation Killer, Lentemul, SEE Dalapon* Dalapon Na, Ded Weed, Devipon, Gramevin, Revenge, Unipon, Dowpon M, Radapon, Basfapon, Basinex P and N, Revenge Dibromochloropropane (DBCP) Di (2 ethylhexyl) adipate Di (2 ethylhexyl) phthalates Nemafume, Nemanax, Nemaset, BBC 12, Fumazone, Nemagon, Nematocide, Oxy DOA, a plasticizer DOP, DEHP, BEHP, Bisoflex, Eviplast, Octoil, Latimol, Sicol, a plasticizer, DMP, DEP, DAP, DPP, DBP, DIBP, DCP Widely used herbicide on corn, sorghum, turf grass sod, Christmas trees, and non crop land Restricted Use Pesticide (RUP)*** Algicide; pool, aquarium, spa agents Many formulations Cancelled Persistent in Groundwater Not a pesticide Usually found in coal tar Coal tar pitch volatiles Soil fumigant Insecticide for potato, corn, soybean, and ornamentals Banned on all crops in 2009 Soil pesticide for corn and citrus crops Termiticide for termite control Banned for all uses besides termite control in 1980 Highly persistent in environment Banned for all uses in Rhode Island as of 1987 Herbicide for broadleaf weeds Third most commonly used herbicide in North America. Used on crops, primarily corn, and non crop land including turf May be combined with picloram Tendency to leach from soil Herbicide for a broad variety of crops. Used to control grasses in crop and non crop land Threat to drinking water through runoff of contaminated areas. Soil fumigant for nematode control Used on cucumbers, squash, cabbage, calulifower, carrots, pineapples and other crops. Banned for all uses in 1985 Persistent in contaminated soil and groundwater Used as a plasticizer and vinyl resins compound Applied as a solvent, aircraft lubricant, hydraulic fluid, makeups Primary concern from factory discharge to water systems and electrical wires used in wells Used primarilyas a plasticizer for resins and Polyvinylchloride (PVC) Used in Food Processing Primary concern from factory discharge into water systems Affinity to biologically accumulate

22 Chemical Name Trade Name Usage Dinoseb Dioxin (State wide waiver) Diquat (State wide waiver) Endothall (State wide waiver) DNBP, Basanite, Elgetol 318, Helfire, Kiloseb, Nitropon C, Sinox General, Caldon, Chemox, Chemsect, Dinitro, DN 289, Dynamyte, Gebutox, Premerge, Subitex, Unicrop DNBP, Dinitro Weed Killer, Vertac, Dyanap, Spurge, Contact 2,3,7,8 Tetrachlorodibenzo p Dioxin Midstream, Actor, Dextrone, DNBP, Krop, Reglox, Aquacide, Dextrone, Weedtrin D, Klean, Preeglone, Proglone, Weedool, Pathclear Aquathol, Endothal Weed Killer, Hydout, Des i cate, Penco, Weedtrine, Byramin, Weedaway, Hydrothol, Niagrathal, Herbicide 273 Selective pre emergent herbicide on numerous crops such as orchards, vineyards, forage legumes, potato vines, seed crops, onions, garlic, peas, etc. Effectively Banned in 1987 due to correlations with birth defects Not readily Biodegradable Primary concern is soil attenuation preservative for cutting oil, resin emulsions, water based paints, cosmetics, and inks byproduct of some manufacturing processes such as pulp mills or incinerators contaminated batches of 2,4 D and 2,4,5 T(Silvex) herbicide used on aquatic weeds, and in non crop areas potato dessicant Herbicide used on algae and aquatic weeds, Defoliant for agricultural crops Dessicant for lucerne and potatos Endrin Ethylene Dibromide (EDB) Glyphosate* (State wide waiver) Heptachlor Heptachlor epoxide Hexachlorobenzene Hexachlorocyclopentadiene Hexadrin, Endrex, Endrisol, Nendren, Rid a Bird, Endrin Methyl Bromofume, E D Bee, Kopfume, Nephis, Dowfume, Soilbrom, EDB Roundup, Rodeo, Herbolex, Glycel, Honcho, Ranger, Sting, Hockey, Knockout, Shackle, Kleen up, Myster, Accord, Azural, Arcade, Expedite Drinox H 34, Heptamul, Heptox, H 60, Termide, Chlorohepton None Perchlorobenzene, Anticarie, Ceku C.B., HCB, BHC, Perchlorobenzene; Benzene Hexachloride Gamma BHL, Graphlox, Perchlorocyclopentadiene Herbicide Insecticide/Pesticide used on Field crops Most uses were banned in 1980 Restricted Use Pesticide (RUP)*** Threat to drinking water through runoff of contaminated areas Soil and grain fumigant used on vegetable and grain crops Banned 1984 Aquatic herbicide in combination with diquat Additive to leaded gasoline Discontinued with leaded gasoline ban Used as an intermediate for dyes and Resins Persistent in contaminated drinking water non selective herbicide, controls many annual and perennial grasses and broadleaf weeds Termiticide Agricultural and home uses banned in 1978 Continued use in fire ant control, pad mounted electric power transformers and in underground communication cables Degradation product of Heptachlor (above) More toxic than Heptachlor Pesticide Banned in 1965 Formed as the byproduct of the manufacture of other chemicals Attenuation in soil environments Biologically Accumulates Intermediate in the synthesis of cyclodiene insecticides Primary concerns for oral and inhalation exposure Threat to drinking water through factory discharge and emission residue. Lindane BHC) (Gamma Agronexit, Silvanol, Forlin, Gamaphex, Gammex, Isotox, Lacco Hi Lin, Lacco Lin O Mulsion, Lindagam, Lin O Sol, Novigam, Agrox 3 Way, Gamatin, Germate, Vitavax, Grano, Landafor, Lintox, Nexit, Novigam, Lindafor, Gamma Hexachlorocyclohexan, gamma HCH, Gamallin Insecticide used for fruit and vegetable crops (most uses restricted in 1983) Currently used for treating wood inhabiting beetles Restricted Use Pesticide pet product for parasite control Primary concerns are oral ingestion through contaminated crops, leaching to aquifer and runoff into surface water.

23 Chemical Name Trade Name Usage Methoxychlor** Oxamyl Picloram* Polychlorinated Biphenyls (PCBs) Pentachlorophenol Simazine Toxaphene Double M, Chemform, Flo Pro McSeed Protectant, Moxie, AlfaTox, DMDT, Dual, Pennant, Dueler, Medal, Ontract, Methoxcide, Dimethoxy DDT, Methoxy DDT DPX 1410, Vydate, Thioxamyl, N,N Dimethyl 2 methyl carbamoyloxino 2 (dimethylthio) acetamide Amdon, Borolin, K Pin, Access, Tordon, Grazon Arochlor, Phenochlor, Kanechlor Penta, Penwar, Pentacon, Penta Ready, Penta WR, Penta Plus 40, Penta EC 30, Penta Preservative Ready to Use, Glazd penta and Block penta, Penchlorol, Sinituho, Antimicrobial, Dow Pentachlorophenol DP 2, Dowicide EC 7, Priltox, Santobrite, Santophen, PCP, Chlorophen, Chlon, Dowicide 7 Cekusan, Framed, Caliber 90, Simadex, Aquazin 80 W, Amizine, Simazol, Remtal SC, Pathclear Camphoclor, Motox, Phenacide, Phenatox, Strobane T 90, Toxakil, Toxon 63, Attac, Motox, Phenatox, Polychloro camphene 2,4,5 TP 2,4,5 Trichlorophenoxy propionic acid, Silvex, Aqua Vex, Frutone T, Kurosal, Weed B Gon, Amchem 2,4,5 TP, Ded Weed, Double Strength, Kuron, Silvi Rhap, T Nox, Fruitone, Esteron, Brush B Gone, Fence Rider, Line Rider, Fenoprop *Commonly found at right of ways **Commonly found in households ***Restricted use as per RI Department of Environmental Management regulation Multi use insecticide used on fruit and shad trees, vegetables, home gardens, around farm buildings, and pets. Toxicity All uses effectively Banned in 2003 Primary concerns are physical exposure and drinking contaminated water from runoff Insecticide, nematicide used for certain insects, mites, and/or nematodes Used on many field crops, fruits and vegetables Restricted Use Pesticide (RUP)*** Primary threats to drinking water include run off from contaminated areas and leaching into groundwater. Systemic herbicide used deeply rooted or woody plants Used for right of way weed control Affinity to leach which poses a threat on ground and drinking water Highly persistent in environment Runoff of contaminated areas, also poses a threat to drinking water. May be combined with 2,4 D Restricted Use Pesticide (RUP)*** Most products cancelled Used primarily in the electrical industry (transformers) Banned in 1979 Used in the dielectric fluid (non food grade) of submersible well pump s capacitor Banned in 1979 Environmentally Persistent Major concerns of contamination through the gradual leaking of fluid from older submersible pumps Used as a biocide to control microorganisms Banned for these uses in 1987 Currently used as a wood preservative Restricted Use Pesticide Primary concerns for exposure are inhalation and oral consumption through contaminated water runoff. Persistence in finished drinking water Pre emergence herbicide for control of most annual grasses, broad leaf weeds, corn, and common lawn weeds. Restricted Use Pesticide (RUP)*** Used widely on deep rooted crops such as artichokes, asparagus, berries, and citrus. Commonly combined with paraquat Primary concern for exposure is contaminated water runoff. Most products cancelled Widely used pesticide and herbicide on many food and nonfood crops Persistent in the Environment. Banned internationally in 2001 Primary modern concerns include leaching from historically contaminated areas. Herbicide used on fence rows, rights of way, golf courses, Rice, bluegrass, sugarcane and aquatic waterways Banned 1983 Used extensively by Military Primary modern concerns include gradual leaching from historically contaminated areas.

24 Description of RIDEM Regulated Facilities CERCLIS EPA listed Comprehensive Environmental Response Compensation and Liability Information System. Contains wide range of known and potential waste sites, including but not limited to, landfills, dumps and EPA Superfund sites listed in the 1990s or earlier. Many are potential sites without monitoring data. Dam Location and flood / safety hazard rating of dams and related structures on rivers or streams regulated by RI DEM, circa (Not a potential source of pollution to water supply wells.) Environmental Land Usage Restriction Sites where a file related to the location exists within the RIDEM Office of Waste Management. These are typically end results of cleanups or engineered controls where the contamination has been removed, remediated and/or managed to the extent feasible. To limit the risk to human health and prevent the risk of water infiltration and residual contaminant movement, the project is closed out with restrictions on future typically prohibiting regrading, disturbance of impermeable barriers, and stormwater infiltration. This group is included within the RIDEM Site Investigation and Remediation sites. EPA Superfund (NPL) National Priorities List of the sites posing the greatest threats to human health and the environment. The list is used primarily to guide the EPA in determining which sites warrant further investigation. This group is included within the CERCLIS sites. RIDEM Site Investigation and Remediation (2013) A DEM investigation has been conducted and a file record exists. This is the most current list of DEM site investigations and monitoring results. It includes closed out sites with Environmental Land Usage Restrictions, as well as sites with ongoing investigations or cleanups. RIPDES Sanitary Waste Sites Rhode Island Pollution Discharge Elimination System point locations for all sanitary waste sites (such as municipal wastewater treatment facility discharges) where permits have been issued by RIDEM. RIPDES Non Sanitary Waste Sites Rhode Island Pollution Discharge Elimination System point locations for all nonsanitary waste sites (such as cooling water) where permits have been issued by RIDEM. Stormwater Outfall Stormwater outfall / discharge point of a Municipal Separate Storm Sewer System (MS4) owned by either RIDOT or by any municipality, other state agency or institution regulated under the RIPDES stormwater program. Storage Tank Above Ground (2009) Storage tanks regulated by RIDEM. Storage Tank Underground (2014) Storage tanks regulated by RI DEM. Storage Tanks Underground L UST (2014) Underground storage tanks and associated piping used for petroleum and certain hazardous substances that have experienced leaks as determined by RIDEM. Stormwater Multi Sector General Permit Stormwater outfall / discharge point from industrial facilities regulated by the RIPDES stormwater program. Tier 2 Facility (2011) Business and other facilities required to submit an annual Tier II inventory form for each of the hazardous chemicals present at the facility in quantities equal to or greater than established thresholds, and to have Material Safety Data Sheets (MSDS) under the OSHA Hazard Communication Standard, as required under Section 312 of the Superfund Amendments and Reauthorization Act (SARA) of 1986, also known as the Emergency Planning and Community Right T0 Know Act (EPCRA). Data is reported to the RI Department of Labor and Training, not DEM.

25 Activity Use Survey Form Instructions and Template If your wellhead protection area contains any of the land uses noted in Table 1, the Department of HEALTH strongly encourages you to use the following Activity Use Survey template to gather more information about the true risk of SOC contamination. A completed Activity Use Survey is recommended for each activity noted on that table. The Activity Use Surveys are designed to be given to the owner or manager of the property where the land use from Table 1 has been noted. You can conduct the Activity Use Survey in person, by phone, or you can mail it. Conducting the survey in person or by phone gives you a better opportunity to answer questions about the survey process, but if that isn t possible, the Department of HEALTH has prepared a factsheet about the survey that can be included in a mailing. How Do I Start? You should be able to find business addresses and phone numbers in the Yellow Pages. Land owner addresses can be obtained from the Town s Office of the Tax Assessor. If you are completing the survey with the land owner or manager in person or over the phone, you should fill out one of the survey templates as you talk. If you have to mail the survey, please fill out Section I of the form and the Activity Information in Section 2 before mailing and include: the provided factsheet explaining the survey; a copy of the Regulated SOCs table included in the Appendix; and a stamped, self addressed envelope so that the land owner returns the survey to you. All completed surveys should be included with this application when you return it to the Department of HEALTH. What If The Land Owner Has Additional Questions? If any of the survey recipients wants to verify the authenticity of the survey, please direct their calls to the HEALTH Office of Drinking Water Quality If the survey recipient has questions that you cannot answer, please direct their call to the Office of Drinking Water Quality for technical assistance at

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27 You Can Help! Please Complete The Activity Use Survey! Why Am I Receiving A Survey? This survey is part of a waiver application that a local public water system is providing to the RI Department of HEALTH. The waiver application allows a public water system to request a reduction in water monitoring requirements, specifically the testing of Synthetic Organic Chemicals (SOCs). As part of that application, the public water system needs to determine if regulated SOCs have been used, stored, or disposed of in the area. The survey was developed to help determine that information. What Are Synthetic Organic Chemicals (SOCs)? Synthetic Organic Chemicals (SOCs) are used as pesticides, insecticides, herbicides, fuel additives, and as other ingredients in manufacturing and industrial processes. They are generally toxic and can have significant health impacts; many are known carcinogens. The Environmental Protection Agency (EPA) amended the Safe Drinking Water Act in 1986 to require the periodic monitoring of regulated SOCs. Because some SOCs are not used in certain areas, the EPA has given state drinking water programs the option of waiving monitoring for certain SOCs. All groundwater public water systems in Rhode Island, serving 3300 persons or fewer, are eligible to apply for monitoring waivers. Each waiver lasts for that three year compliance period. A list of SOCs is being provided to you with a copy of the survey. I m Not A Public Water System Owner, So Why Am I Being Asked To Participate? If you have been asked to complete a survey, it is because you own or manage a business or activity in the area of a public water system. The public water system cannot qualify for reduced water monitoring requirements unless they determine what SOCs have been used, stored, or disposed of in the area, and they cannot do that, without help from you. Are All Businesses And Activities Around This Water System Being Asked To Complete This Survey? No, only businesses and activities that are generally associated with the use, storage, or disposal of these chemicals need to be surveyed. If I Do Not Complete This Survey, Will The Public Water System Owner Be Penalized? The RI Department of HEALTH is mandated by regulation to require all public water systems meeting certain criteria to test for these chemicals, unless the owner can demonstrate that the system should qualify for a waiver. If you do not complete this survey, the water system most likely will be required to monitor for any regulated chemical that is typically used for the activities present in the area surrounding the well(s). Is HEALTH Suggesting That I Shouldn t Use These Chemicals? No. In most cases, the RI Department of HEALTH will have no need to follow up on the information you provide. The intent of the information is merely to determine water monitoring requirements for the public water system, not to affect the practices of local businesses. However, in some cases, HEALTH might contact you to discuss the proper use or disposal of chemicals that are restricted or banned. We all need to recognize that our daily activities can impact local waters, including the water some people use for drinking.

28 Where Do I Send The Survey Once I ve Completed It? The form must be returned to the public water system, and a self addressed, stamped envelope should have been provided for your convenience. It is the public water system s responsibility to include the survey information in their waiver application. I Have Questions. Whom Should I Contact? If you simply want to verify the authenticity of this survey, you may contact the RI Department of HEALTH, Office of Drinking Water Quality at All other questions should be directed to the public water supply that contacted you with the survey.

29 1 Activity Use Survey Section 1. This survey is being sent by the following Public Water System (PWS): PWS Name PWS ID Number PWS Owner s Name PWS Owner s Address PWS Owner s Phone/E mail PWS Operator s Name PWS Operator s Address PWS Operator s Phone/E mail Section 2. This survey is being sent because you own or operate a business or activity near the PWS s well(s) that has the potential to contribute Synthetic Organic Chemicals (SOCs) to that water supply. Business/Activity Type (e.g. farm) Your Name Your Address Your Phone/E mail Your Role Within That Business/ Activity Section 3. 3A. General Information Business/Activity Size (e.g. acres, square feet, etc.) Length of Time In Operation Is the business/activity still in operation? YES NO Has the soil or water been tested for pesticides at this site previously? 3B. SOC Use YES NO UNKNOWN Were any chemicals on the attached SOC list used at this site in the last 10 years? YES NO UNKNOWN If you answered yes above, please list the information requested below:

30 2 Activity Use Survey SOC Used Quantity Frequency of Use Purpose of Use Do you anticipate using any of these chemicals in the future? YES NO UNKNOWN 3C. SOC Storage Were any chemicals on the attached SOC list stored at this site in the last 10 years? YES NO UNKNOWN If you answered yes above, please list the information requested below: SOC Stored Quantity Currently or Previously Stored? 3D. SOC Disposal Were any chemicals on the attached SOC list disposed of at this site in the last 10 years? YES NO UNKNOWN If you answered yes above, please list the information requested below: SOC Disposed Of Quantity When Where This form was completed by:

31 Previous Waiver Notes

32 Map Of Your Wellhead Protection Area (WHPA)