28 VARNEY STREET (AKA 16 PROCTOR STREET) RNF 1-18-18 C) ONANI RECEIVED
ENVIRONMENTAL GROUP
JAN 2 2 202
January 18,2018
CITY OF SALEM
Mayor Kimberly Driscoll BOARD OF HEALTH
Salem City Hall
93 Washington Street
Salem, MA 01970
Re: Release Notification Form
Commercial Property
28 !Varney Street(aka 16 Proctor Street),Salem,MA
MassDEP RTN— To Be Issued
OEG Project No. 4098
Dear Mayor:
In accordance with the Massachusetts Contingency Plan (MCP) [(310 CMR
40.1403(3)(h)] and on behalf of Malik Embossing Corporation (as the potentially
responsible party), the purpose of this letter is to:
• Notify the City of Salem of a release of petroleum hydrocarbons that has been
identified at the above-referenced Site. The enclosed copy of the Release
Notification Form (RNF) (BWSC-103), which was submitted to the
Massachusetts Department of Environmental Protection (MassDEP) as a 120-day
reporting condition, provides more information concerning the release (a release
tracking number [RTN] will be issued by MassDEP]; and
• Notify you of your rights to request additional Public Involvement Activities
under 310 CMR 40.1403(9), as applicable,and upon Tier Classification, if
performed, under 310 CMR 40.1404.
I
Please do not hesitate to contact the undersigned at (978) 256-6766 if you have any
questions, comments, or require additional information.
Sincerely,
Omni Environmental Group
0'ep y �aead
Gregory R. Morand, LSP
Principal
cc: Mr. Larry Ramdin, Health Agent, Salem City Hall, 93 Washington Street, Salem, MA
01970
6 Lancaster County Road• Harvard, MA 01451
Telephone: (978)256-6766 •www.OmniEG.com
Massachusetts Department of Environmental Protection BWSC103-120 DAY
Bureau of Waste Site Cleanup
Release Tracking Number
RELEASE NOTIFICATION FORM
assigned upon receipt and
Pursuant to 310 CMR 40.0371 (Subpart C) review by the Department
A. RELEASE OR THREAT OF RELEASE LOCATION:
I.Release Name/Location Aid: COMMERCIAL PROPERTY
2.Street Address: 28 VARNEY ST
3.City/Town: SALEM 4.ZIP Code: 019700000
5.Coordinates: a.Latitude:N 42.51843 b.Longitude: W 70.91059
B. THIS FORM IS BEING USED TO:
13 I.Submit a Release Notification for a 120 day reporting requirement
(All sections of this transmittal form must be filled out)
C. INFORMATION DESCRIBING THE RELEASE:
1.Date and time you obtained knowledge of the Release: 11/30/2017 Tine: 0l.W r AM r PM
mm/dd/yyyy hh:mm
2.Date and time release occurred,if known: r- Time: F- r AM r PM
mm/dd/yyyy hh:mm
3.120 DAY REPORTING CONDITIONS
Check all Notification Thresholds that apply to the Release:
(for more information see 310 CMR 40.0315)
r a.Release of Hazardous Material(s)to Soil or Groundwater Exceeding Reportable Concentration(s)
iv b.Release of Oil to Soil Exceeding Reportable Concentrations)and Affecting More than 2 Cubic Yards
r c.Release of Oil to Groundwater Exceeding Reportable Concentration(s)
r d.Subsurface Non-Aqueous Phase Liquid(NAPL)Equal to or Greater than 1/8 Inch(.01 feet)and Less than 1/2 Inch(.04 feet)
Revised: 10/11/2013 Pagel of 3
Massachusetts Department of Environmental Protection BWSC103-120 DAY
Bureau of Waste Site Cleanup
Release Tracking Number
RELEASE NOTIFICATION FORM assigned upon receipt and
Pursuant to 310 CMR 40.0371 (Subpart C) review by the Department
C. INFORMATION DESCRIBING THE RELEASE(cont.)
4.List below the Oils(0)or Hazardous Materials(HIM)that exceed their Reportable Concentration(RC)or Reportable Quantity(RQ)by the
greatest amount.
r Check here if an amount or concentration is unknown or less than detectable.
O or HM Released CAS Number, O or HIM Amount or Units RCs Exceeded,if Applicable
if known Concentration (RCS-1,RCS-2,RCGW-1,
RCGW-2)
C9-C18 O 5000 MGMG RCS-1
C19-C36 0 8500 MG/KG RCS-1
C11-C22 0 11000 MG/KG RCS-1
C9C10 O 1200 MG/KG RCS-1
r Check here if a list of additional Oil and Hazardous Materials subject to reporting,or any other documentation relating to this notification
is attached.
D. PERSON REQUIRED TO NOTIFY:
I.Name of Organization: MALIK EMBOSSING CORPORPRTION
2.Contact First Name: FRANCIS 3.Last Name: MALIK
4.Street 28 VARNEY STREET 5.Title: PRESIDENT
6.City/Town: SALEM 7.State: MA 8.ZIP Code: 019700000
9.Telephone: 978-745-6060 10.Ext.: 11.Email: lvmalik@gmail.com
r- 12.Check here if attaching names and addresses of owners of properties affected by the Release,other than an owner who is
submitting this Release Notification(required).
E. RELATIONSHIP OF PERSON TO RELEASE:
r I.RP or PRP r a.Owner r b.Operator r c.Generator r d.Transporter
r e.Other RP or PRP Specify:
r 2.Fiduciary,Seemed Lender or Municipality with Exempt Status(as defined by M.G.L.c.21 E,s.2)
r 3.Agency or Public Utility on a Right of Way(as defined by M.G.L.c.21 E,s.50))
r 4.Any Other Person Otherwise Required to Notify Specify Relationship:
Revised: 10/11/2013 Page 2 of 3
Massachusetts Department of Environmental Protection BWSC103-120 DAY
Bureau of Waste Site Cleanup
'•�\ Release Tracking Number
RELEASE NOTIFICATION FORM assigned upon receipt and
1 Pursuant to 310 CMR 40.0371 (Subpart C) review by the Department
F.CERTIFICATION OF PERSON REQUIRED TO NOTIFY:
1.1.FRANCIS MALIK ,attest under the pains and penalties of perjury Ill that 1 have personally
examined acid am familiar with the information contained in this submittal,including any and all documents accompanying this transmittal
form,(ii)that.based on my inquiry of those individuals immediately responsible for obtaining the information,the material information
contained in this submittal is,to the best of my knowledge and belief,true,accurate and complete,and(iii)that 1 am fully authorized to make
this attestation on behalf of the entity legally responsible for this submittal. I/the person or entity on whose behalf this submittal is made
am/is aware that there are significant penalties,including,but not limited to,possible fines and imprisonment,for willfully submitting false,
inaccurate,or incomplete information.
2.By: FRANCIS MALIK 3.Title: PRESIDBJf
Signature
4.For: MALIK EMBOSSING CORPORARTION S.Date: i/18=18
(Name of person or entity recorded in Section D) mm/dd/yyyy
r 6.Check here if the address of the person providing certification is different from address recorded in Section D.
7.Street
8.City/To": 9.State: 10.ZIP Code:
I L Telephone: 12.ExL: 13.Email:
YOII ARE SURIECI TO ANNUAL COMPLIANCE ASSURANCE FEES FOR EACH BILLABLE YEAR FOR TIER
CLASSIFIED DISPOSAL SITES.YOU MAST LEGIBLY COMPLETE ALL RELEVANT SECTIONS OF THIS FORM
OR DEP MAY RETURN THE DOCUMENT AS INCOMPLETE.R YOU SIBMIT AN INCOMPLETE FORM,1 Ot'
MAY BE PENALIZED FOR MISSING A REQUIRED DEADLINE.
Date Stamp(DEP USE ONLY:)
Received by DEP on 1/182018 9:53:39 AM
Revised: 10/11/2011 Page 3 of 3