Form H Soil Contamination Review Questionnaire
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- Darcy Small
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1 All applications for rezoning, subdivision, development permit, development variance permit, soil removal permit and demolition permit are to be accompanied by a completed questionnaire in order to determine if your site will be subject to the Ministry of Environment's Site Profile review for contaminated soil. Please fill out and sign the following sections. If you are not the owner of the land, please complete the owner authorization section of the land use and development application form. Staff will evaluate this questionnaire and advise you if a Site Profile application will be required. If a Site Profile is required, it will be processed in parallel with your land use and development application. Completed Site Profiles submitted to the Corporation will be forwarded to the Ministry of Environment for evaluation. Staff are not able to approve your land use and development application until this evaluation is completed by the Ministry of Environment. 1. GENERAL INFORMATION Name of Applicant The person completing this questionnaire is the: owner agent Last First Middle Initial(s) Company Address City Province Postal Code Telephone ( ) - Fax ( ) - 2. SITE INFORMATION Civic Address and Legal Description Contact Us: or CPD@delta.ca Page 1 of 5
2 3. PRELIMINARY USE ASSESSMENT Please indicate if there is currently or to the best of your knowledge if there has previously been any use or activity listed below. Please indicate "Yes" or "No" for each purpose or activity listed below. A. Chemical industries and 1. adhesives manufacturing or wholesale bulk 2. chemical manufacturing or wholesale bulk 3. explosives or ammunition manufacturing or wholesale bulk 4. fire retardant manufacturing or wholesale bulk 5. fertilizer manufacturing or wholesale bulk 6. ink or dye manufacturing or wholesale bulk 7. leather or hides tanning 8. paint, lacquer or varnish manufacturing, formulation, recycling or wholesale bulk 9. pharmaceutical products manufacturing 10. plastic products (foam or expanded plastic products) manufacturing 11. textile dying 12. pesticide manufacturing, formulation or wholesale bulk 13. resin or plastic monomer manufacturing, formulation or wholesale bulk B. Electrical equipment industries and 1. battery (lead acid or other) manufacturing or wholesale bulk 2. communications stations using or storing equipment that contains PCBs 3. electrical equipment manufacturing, refurbishing or wholesale bulk 4. electrical transmission or distribution substations 5. electronic equipment manufacturing 6. transformer oil manufacture, processing or wholesale bulk C. Metal smelting, processing or finishing industries and 1. foundries or scrap metal smelting 2. galvanizing 3. metal plating or finishing 4. metal salvage operations 5. nonferrous metal smelting or refining 6. welding or machine shops (repair or fabrication) D. Mining, milling or related industries and 1. asbestos mining, milling, wholesale bulk or shipping 2. coal coke manufacture, wholesale bulk or shipping 3. coal or lignite mining, milling, wholesale bulk or shipping 4. milling reagent manufacture, wholesale bulk or shipping. 5. nonferrous metal concentrate wholesale bulk or shipping 6. nonferrous metal mining or milling E. Miscellaneous industries, operations or 1. appliance, equipment or engine repair, reconditioning, cleaning or salvage 2. ash deposit from boilers, incinerators, or other thermal facilities 3. asphalt tar roofing manufacture, wholesale and distribution 4. coal gasification (manufactured gas production) 5. medical, chemical, radiological or biological laboratories 6. rifle or pistol firing ranges 7. road salt facilities Contact Us: or Page 2 of 5
3 8. measuring instruments (containing mercury) manufacture, repair or wholesale bulk 9. dry cleaning facilities or operations and dry cleaning chemical 10. sites which have been or likely have been contaminated by substances migrating from other properties 11. controlled substances, as defined in the Controlled Drug and Substances Act (Canada), manufacturing or operations F. Petroleum and natural gas drilling, production, processing, retailing and distribution 1. petroleum or natural gas drilling 2. petroleum or natural gas production facilities 3. natural gas processing 4. petroleum coke manufacture, wholesale bulk or shipping 5. petroleum product dispensing facilities, including service stations and card locks 6. petroleum, natural gas or sulphur pipeline rights of way excluding rights of way for pipelines used to distribute natural gas to consumers in a community 7. petroleum or natural gas product or produced water in above ground or underground tanks 8. petroleum product wholesale bulk or distribution 9. petroleum refining wholesale bulk or shipping 10. solvent manufacturing or wholesale bulk 11. sulphur handling, processing or wholesale bulk and distribution G. Transportation industries, operations and related 1. aircraft maintenance, cleaning or salvage 2. automotive, truck, bus, subway or other motor vehicle repair, salvage or wrecking 3. bulk commodity or shipping (e.g. coal) 4. dry docks, ship building or boat repair 5. marine equipment salvage 6. rail car or locomotive maintenance, cleaning, salvage or related uses including rail yards 7. truck, rail or marine bulk freight handling H. Waste disposal and recycling operations and 1. antifreeze bulk or recycling 2. barrel, drum or tank reconditioning or salvage 3. battery (lead acid or other) recycling 4. biomedical waste disposal 5. bulk manure stockpiling and high rate land application or disposal (non-farm applications only) 6. construction demolition material landfilling 7. contaminated soil, treatment or disposal 8. dredged waste disposal 9. dry cleaning waste disposal 10. electrical equipment recycling 11. industrial waste lagoons or impoundments 12. industrial waste, recycling or landfilling 13. industrial wood waste (log yard waste, hog fuel) disposal 14. mine tailings waste disposal 15. municipal waste, recycling, composting or landfilling 16. organic or petroleum material landspreading (landfarming) 17. sandblasting waste disposal 18. septic tank pumpage or disposal 19. sewage lagoons or impoundments 20. special (hazardous) waste, treatment or disposal 21. sludge drying or composting 22. street or yard snow removal dumping 23. waste oil reprocessing, recycling or bulk 24. wire reclaiming operations Contact Us: or CPD@delta.ca Page 3 of 5
4 I. Wood, pulp and paper products and related industries and 1. particle board manufacturing 2. pulp mill operations 3. pulp and paper manufacturing 4. treated wood at the site of treatment 5. veneer or plywood manufacturing 6. wafer board manufacturing 7. wood treatment (antisapstain or preservation) 8. wood treatment chemical manufacturing, wholesale bulk 9. sawmills 4. EXEMPTION REVIEW Under certain circumstances, you may be exempt from applying for a Site Profile even if you answer "yes" in the previous section. Please review and indicate if any of the following applies. Please attach copies of applicable correspondence from the Ministry of Environment regarding soil issues. Exemptions related to the site: A Site Profile that is on file at the Site Registry contains all current information about areas on the site. Please state filing date and file reference number used by the Ministry of Environment. The Regional Manager at the Ministry of Environment has already made a decision in regards to contamination or rehabilitation, such as approval in principle, certificate of compliance, etc. Please attach any correspondence from the Ministry or state the type and the date of the decision, and the Ministry of Environment file reference number. The site is a Wide Area Site designated by the Regional Manager and an approved remediation plan applies. Please elaborate. The site has been determined by the Regional Manager at the Ministry of Environment to be contaminated, provided there is no additional or new contamination following such a determination. Please state the date of this determination and the Ministry of Environment file reference number. Contact Us: or CPD@delta.ca Page 4 of 5
5 The site was satisfactorily remediated before April 1, 1997, there is no change in use or, and there is no new site contamination. Please provide written confirmation of satisfactory remediation status and the Ministry of Environment file reference number. Exemptions related to the application: The subdivision application is for a Statutory Right-of-way of the Land Title Act. The development permit or development variance permit application will not result in construction or involve disturbance or excavation of soil. Please elaborate on the purpose of the application. Attach a separate sheet if required. The application for building demolition is not associated with decommissioning of the site. Please elaborate on the purpose of the application. Attach a separate sheet if required. 5. SIGNATURE The person completing this questionnaire states that the above information is true, based on the person's current knowledge as of the date completed. Person Completing Questionnaire (Signature) Please Print Your Name Date Signed Owner authorization form completed and attached if person completing this questionnaire is not the owner. 6. OFFICIAL USE File Number Site Profile: Required Not required Date Received Contact Us: or CPD@delta.ca Page 5 of 5
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