[From the U.S. Government Printing Office, www.gpo.gov]




                                                                                       Project #93.4.13






                             TOWN, OF EXETER, N.H,
                              off




                            WELLHEAD PROTECTION
                                                   PROGRAM/

                                                            1995




                This report was funded in part by a grant from the Office of State                  Planning, New
                Hampshire Coastal Program, as authorized by the National Oceanic and Atmospheric
                Administration (NOAA), Grant Award Number NA370ZO277.


                     TD
                     224
                     E92
                     T69
                     1995
                     c2


                                      Nit Coastal Program
                                                                                    %@"Qcsa OF









               DRAFT: JUNE 1995


               APPLICATION FOR GROUNDWATER RECLASSIFICATION
               TOWN OF EXETER, NEW HAMPSHIRE


               The Town of Exeter is requesting to reclassify all of the Town's groundwater resources to the GAA
               classification. The primary reasons for requesting a GAA classification are as follows:

                       The Town's populace is almost entirely dependent on groundwater resources for their
                       drinking water.

                       As is typical of municipalities with a diversified tax base, Exeter contains many businesses
                       which use potentially hazardous substances during their normal course of operation. The
                       Town wants to ensure that these businesses are operating in a manner which does not
                       threaten Exeter's groundwater resources.

                       The Town of Exeter would like to develop a more pro-active approach to protect is natural
                       resources, with particular emphasis on its groundwater resources.

               In accordance with the Reclassification Check Sheet for GAA and GA I Areas, as prepared by the
               Department of Environmental Services, the following infonnation is provided:

               I       DES Request form for Groundwater Reclassification to GAA (420.03-1!1
                       See attached form signed by Town ManagerGeorge Olson and a copy of the minutes of the
                       June 19, 1995 meeting of the Exeter Board of Selectmen. At this meeting the Board of
                       Selectmen voted to proceed with the implementation of the Wellhead Protection Program.

               2.      WHPA Delineation
                       See attached WHPA delineation, prepared by DES employee, Judy Malone, and a GIS map,
                       prepared by the Rockingham Planning Commission GIS Specialist. This NNWA delineation
                       indicates 4,000 foot radii around Skinner Springs well, which is located in Stratharn, New
                       Hampshire, and around Gilman, Stadium and Larry's Lane wells, which are all located in
                       Exeter, New Hampshire.

                       The accompanying Phase I Wellhead Protection Area (WHPA) Maps for Exeter's Skinner
                       Springs well in Stratham, and the Gilman, Stadium and Larry's Lane wells in Exeter show the
                       political boundaries of Exeter, the well locations for all Exeter public active water sources in
                       the adjacent communities of Stratharn and Kensington, the local road network, all existing tax
                       parcels, the well locations for all public active water sources in the Town of Exeter, the
                       stratified drift aquifers, and the Potential Contamination Sources (PCSs) identified in the
                       inventory. The political boundaries and road network as they appear on the maps are based
                       on information obtained from the State's GRANIT system. The GRANIT system can provide
                       GIS-based coverages for local road networks and political boundaries based on the USGS 7.5
                       series of topographic maps.










               Exeter Wellhead Protection Program
               Reclassification/ Management Plan
               Page 2.



                      Description of Informational Meetint!
                      The informational meeting was advertised in the Exeter lVewsletter on Tuesday, June 20 and
                      June 27, 1995. Notices were posted at least 10 days in advance of the meeting at the Shaws
                      Market in Stratham, the Exeter Town Library and in the Exeter Town Offices. (See
                      attachments of legal notice and public notice)

                      The meeting was held on Tuesday, June 27, 1995 at 7:30 pm. in the Exeter Town Offices.
                      The meeting was held in the Nowak Room, which is located on the second floor. There were
                      over twelve people in attendance at the meeting. The following people were present:


                      Keith Noyes            Director of Public Works       Town of Exeter
                      George Olson           Town Manager                   Town of Exeter
                      P. J. Hoyt             Exeter & Hampton Electric      Exeter/Kensington
                      Brian Comeau           Assistant Fire Chief           Town of Exeter
                      Jean and Ralph Pynn    Pynn's Auto                    Portsmouth Ave, Stratharn
                      David O'Brian          Exeter & Hampton Electric      Exeter/Kensington
                      Jerrold DuPont         Toyota- Portsmouth Ave         Exeter
                      Sarah Pillsbury        NHDES                          Concord
                      Debbie Soule           HNDES                          Concord
                      Betsy Ware              RPC                           Exeter
                      George Bragg           Phillips Exeter Academy        Exeter
                      representatives from the Exeter Newsletter, Portsmouth Herald and Foster's Daily Democrat

                      The meeting was divided into three components: an introduction and a project overview from
                      the Rockingham Planning Conunission; an overview of the State's Wellhead Protection
                      Program by DES representative; and, finally, a question and answer period.

                      It was noted at this meeting that the Town of Exeter matched a $3,750. New Hampshire
                      Office of State Planning Coastal Program Grant. It was also noted that the conununity of
                      Exeter would save approximately $5,000 to $10,000. per year in costs savings if the
                      groundwater was reclassified and the Town of Exeter started a monitoring program.









                  Exeter Wellhead Protection Program
                  Reclassification/Management Plan
                  Page 3.



                  4.      PCS Inventory Report

                          Inventory inspections were conducted by Town of Exeter Assistant Fire Chief/Health Officer
                          Brian Comeau and RPC senior planner Betsy Ware in June and July, 1995. These
                          inspections were completed in accordance with Env. -Ws 420. 10 to confirm the existence of
                          and/or activity of PCSs within the wellhead areas. Inventory sheets, prepared by the N. H.
                          Department of Environmental Service, were used to determine whether a site was using
                          regulated substances and was a Potential Contamination Source (PCS). Property managers
                          and/or owners were requested to complete the inventory on the inventory sheets- indicating
                          the type and quantity of regulated substances used and stored on the property. Detailed
                          questions were asked regarding the storage, use, and disposal of all regulated substances.

                          These inspections also were conducted to confirm the operation of PCSs indicated in the
                          attached 1993 Town of Exeter Water Management and Protection program. This plan
                          includes mapping of PCSs for the Town of Exeter, locations of wells and aquifers. (It should
                          be noted that the locations of wells in tl-@s report is inaccurate and that the locations of wells
                          shown on the wellhead protection areas are accurate.)

                          The inventory of potential contamination sources (PCSs) for the 1993 study was based on
                          State -data bases as well as on field work conducted by the Rockingham Planning
                          Commission. The inventory includes the site address, tax map and lot number, property
                          owner and address, site contact person and an identification of the potentially haZA dous
                          activity in question. Presented below are the sources uï¿½ed to develop the potential
                          contamination source inventory.

                          A.      The DES Groundwater Protection Bureau provided access to several data bases
                                  including: sites listed in their groundwater hazard inventory, holders of Groundwater
                                  Discharge Pern-lits, sites contairuing underground storage tanks (USTs), State-
                                  permitted solid waste facilities, Superfund sites and those facilities regulated under the
                                  Resource Conservation and Recovery Act (RCRA).

                          B.      The DES Water Supply and Pollution Control Division (WSPCD) provided the RPC
                                  with a list of the region's National Pollution and Discharge Elimination System
                                  (NPDES) permit holders. Four NPDES permit holders were identified in Exeter.

                          C.      The Toxic Release Inventory data sheets on file with the Town's Health Officer were
                                  reviewed.


                          D.      The RPC compiled a list, based on a windshield survey, the Exeter Water Resources
                                  Management and Protection Plan and reviewing the Town's tax maps, of potential








                Exeter Wellhead Protection Program
                Reclassification/Management Plan
                Page 4.

                                contan-driation sources (PCSs)

                                A draft list of potential contamination sources was compiled from the above data
                                sources. A detailed inventory, which includes estimates of the type and quantities of
                                regulated substances used and/or generated as waste materials is in the process of
                                being prepared based on the inventory inspections. Once the State has approved the
                                Town's management plan further detail will be obtained and provided.

                                No inspections were conducted by Exeter officials in the towns of Stratharn or
                                Kensington. Inspection reports for properties within the Town of Stratharn are in the
                                process of being obtained from the Town of Stratharn Code Enforcement Officer,
                                who has been conducting inspections and reports for the Stratham, Wellhead
                                Protection Program. Since there have not been any PCSs identified in Kensington,
                                inspections were not necessary. The attached letters sent to both Stratharn and
                                Kensington indicate that the Town of Exeter is eager to establish a cooperative
                                agreement for WHPA inspections with each of these communities.

                                The attached Town of Exeter Water Management and Protection Program , with
                                associated maps, include the locations of the PCSs. While generally accurate, these
                                maps are being further checked to confirm whether more PCSs exist in the WHPAS.



                5. Potential Contamination Source Mannement Plan (420.12 and RSA 485-C:8)


                        The Wellhead Protection Prograas management plan essentially consists of the Town of
                        Exeter's plans for managing the potential contamination sources (PCSs) located within the
                        reclassified area. The management plan for the Town of Exeter's Wellhead Protection
                        Program will involve the following tasks:

                        A. The update of the potential contamination source inventory will occur at least once every
                        three years and will be based on the Public Works Department and the Health Department's
                        records for the previous year, as well as the building permit and occupancy/use permit records
                        maintained by the Building Inspection Departments in the Town of Exeter, the Town of
                        Kensington and the Town of Stratham.

                        B. The owners of Exeteespotentially hazardous land uses will be notified by the Town that
                        their business is located within a wellhead protection area. This letter will include a
                        statement that the activities of the identified business fall under the State's definition of a
                        potential groundwater contamination source (as defined by RSA 485-C). The lettef will
                        infonn the business owner of the need to comply with the State's Best Management Practices
                        administrative rules (Env-Ws; 421). A set of these regulations, as well as public information,










                  Exeter Wellhead Protection Program
                  Reclassification/Management Plan
                  Page 5.


                          will be included with the letter. It should be noted that as inventory inspections to PCSs have
                          been made, the Exeter Assistant Fire Chief and RPC Senior Planner Betsy Ware have been
                          providing copies of the Best Management Practices (Part Env-Ws 42 1) the Dos and Don'ts
                          Flyer and the DES Fact Sheet on Groundwater Reclassification to these businesses.

                          The letter will also inform the owner that any unperm@itted discharges to the groundwater,
                          or contarnination of groundwater, are illegal under RSA 485-A: 13 and Env-Ws 4 10.

                          The letter will also indicate that representatives from the Town will be scheduling Best
                          Management Practices (BMP) compliance inspections in the near future, and the name and
                          telephone number of the local contact person, who can answer specific questions relating to
                          Exeter's Wellhead Protection Program (At present it will be the Assistant Fire Chief/Code
                          Enforcement Officer, Brian Comeau and Public Works Director Keith Noyes) . This letter
                          will essentially be the "Sample Letter to Property Owners" included within the Model Health
                          Ordinance to Implement a Wellhead or Groundwater Protection Program, prepared for
                          DES by the New Hampshire Office of State Planning. This sample letter will be modified to
                          delete all references to a local health ordinance and a more direct reference will be made to
                          the Town's Wellhead Protection Program.

                          C.    Best Management Practices (BMP) compliance inspections for the Potential
                          Contarriination Sources (PCSs) located within the Wellhead Protection Areas (WHPAs) will
                          be scheduled at least once every three years. The Exeter Health Department would,
                          however, like to take a more pro-active role in the protection of its water supplies and,
                          therefore, may inspect more frequently if necessary or as time permits. The municipal
                          inspection will make use of the "Potential Contamination Source Inspection Fonn" as
                          presented in the document, Model Health Ordinance to Implement a Wellhead or
                          Groundwater Protection Program, prepared for DES by the New Hampshire Office of
                          State Planning.

                          D. New businesses which are subsequently added to the inventory will have their inspection
                          cycle begin within the first year of their operation. The Health Department will inform new
                          businesses operating within the Wellhead Protection area of the need to comply with the
                          State!s BW administrative rules, and the necessity of periodic BMP compliance inspections.
                          Portsmouth's Inspection Department will inform new businesses of the City's Wellhead
                          Protection Program when they apply for a building permit, an occupancy/use permit and/or
                          a permit to store or use substances which come under applicable state and/or local laws.

                          E. The City shall provide written notice of BMP violations to the owner of the potential
                          contamination source within thirty (30) days of the date of the BMP compliance inspection.








                       F. Inability to gain access to a potential contamination source for the purpose of conducting
                       a BMP compliance inspection shall be reported by the Exeter Health Department to the DES
                       Water Supply and Pollution Control Division.

                       G. BW educational materials will be provided to agricultural operations which are not
                       included in the active management plan. All agricultural operations shall be inspected and
                       monitored by the New Hampshire Department of Agriculture for compliance with their
                       agricultural Best Management Practices.

                       Initial B&T compliance inspections will begin in late 1995.







               attachments
               d:\towns\exeter\admin\rect ass



















                                                               NEW HAMISHIRE
                                                               DEPAR7MENTOF
             REQUEST FOR RECLASSIFICATION FORM             Environmental
                                                                 Services
                      Date. June 30, 1995


                 LocalEntity: Town of -Exeter, New Hampshire
                 Address: 10 Front Street, Exeter, New Hampshire

                 ContactPerson: Brian Comeau, Health Officer Phone: 778-0591



                 We request reclassification of groundwater to: CIRCLE ONE

                                 GAA            GAI


                 The groundwater protection area to be reclassified is located in:


                  Exeter, Stratham and Kensington, New Hampshire
                               (name(s) of municipality(ics))

                 The name(s) of the 7.5' USGS quadrangle map(s) showing the proposed
                 groundwater classification:

                   Exerer




                 The followinp- are attached to this form: (please check)

                 1.   Wellhead Protection Area Delineation (GAA) M
                                     OR
                      Definition of High Value Groundwater (GAI) (
                 2.   Potential Contamination Source Inventory ( X)
                 3.   Potential Contamination Source Management Plan X)


                 If the local entity is a town or city, the local governing body (Board of
                 Selectmen, City or Town Council), shall indicate its concurrence with
                 this proposal by signing below:






                      Submit to: New Hampshire Department of Environmental Services
                                Aicn.: Wellhead Protection Program
                                P.O. Box 95. 6 Hazen Drive
                                Concord. N.H. 03301
                                                   &Envi






                    raised at Town Meeting. The difference between the $13,500 and the reduced building
                    cost of $15,907 would be taken out of the Park and Recreation Building emergency
                    maintenance fund.

                    Chaiman Rowe asked how much of a saving would be associated with building a
                       nolithic slab foundation rather than a freeze wall. Mr. Olson responded that W.
                    Lambert stated $300. Mr. Rowe felt that there should be a greater savings than $300.
                    mo


                    Mr. Binette questioned the condition of the building after 6 months 'Aithout siding.
                    W. Olson stated that Mr. Lambent did not feel that there would be a problem. Mrs.
                    Stanley Jones suggested that Mr. Lambert should be asked to warranty the condition of
                    the building without siding for 6 months. Nft. Olson agreed to bring this matter up
                    with Mr. Lambert. Chainnan Rowe sug ted that "Texture I I I " plywood be used in
                                                            ,ges
                    that it was weatherproof and looked better that plain plywood. Mrs. Stanley Jones
                    asked about additional cost. Chairman Rowe stated that it would not be much more
                    expensive.

                    Mr. Bmiette sucy(yested that Mr. Lambert be asked to took aoaln at the savings
                    associated with a monolithic slab v. a freeze wall, putting up Texture I I I siding and
                    warranting the structure for the period it did not have siding. Mr. Scafidl expressed
                              :M                                                 ID
                    his concem over pushing too hard in this matter since Mr. Lambert could refuse to
                                            C)
                    address the issues raised and no building would be built or the Board would have to
                    go back an bid the structure again.

                    Moved by Mr. Scafidi, second by Nts. Stanley Jones to ask Mr Lambert to confinn
                    the possible savings associate with a monolithic slab foundation, dw cost of using
                    Tex-Wre III plywood and his willingness to wan-Anty the condition of the building
                    prior to his placing the siding on the sUwtum SO VOTED

                    6. Action on amendment to Water and Sewer Advisory Conumittee policy

                    Nbved by Nk. Scafidi, second by Nk. St. Atnour to arnend the %ter and Sewer
                    Advisory Committee policy on adjustrnents to delete the words 'Property owners am
                    allowed one adjustrnent per meter and" so that the sentence reads 'Pmf of repair
                    must be provided along with the request for adjustrrient" SO VOTM

                    7. Presentation on Wellhead Protection Proggam

                    Chaim= Rowe asked Mr. Olson to address the issue. Mr. Olson explained that this
                    program was fht brought before the Board several years ago in anticipation of





                Selectmn - Regular 06-19-95
                                                                2








                   receiving financial assistance to get the program underway. Unfortunately at that time
                   the grant application was not successful but this year grant money was received and
                   that the Rockingham Planning Commission was working, on the           *ect. Betsy Weare
                                                                             0        pro)
                   of the RPC was here tonlight to go over the program with the Board in anticipation of
                   a public hearing set for the 27th.

                   IvIs. Weare approached the rriiike and explained the program stressing that the Town
                   will expenience considerable savings each year since it will have to test well water
                   from the site only once a year rather than 4 times a year as is now required by the
                   State. The protection area covers a 4,000' radius from the 4 wells: Stadium, Larry
                   Lane, Skinner Springs and Gilman. The Town will be required to inspect some 25
                   businesses in the protection areas on a annual basis to imure that best management
                   practices are being used by the businesses in storage of materials that could impact the
                   wells. Chief Carbonneau confirmed that these inspections already take place but not
                   on a routine basis as will be required under the proggram.

                   Chairman Rowe suggested that if the program was implemented that the state could
                   condemn a town well for other than a valid reason. Mr. Olson stated that was the
                   current situation and that the state controlled drink-ina water *in the Exeter. He went
                   on to note that the progarn did not give the state more power than it already had, but
                   rather saved the Town money.

                   Mrs. Stanley Jones asked if Ms. Weare knew of a town that had turned the program
                   down? Ms. Weare stated that this was only her second program, the first being
                   Portsmouth and that she did not know of a town that had turned down the program.
                   Mrs. Stanley Jones asked if there was any reason the Town should not proceed with
                   the program9 Ms. Weare could not think of my since it only made inspections
                   already bemig done routine and did not add any additional regulations.

                   Chairman Rowe asked if the state will be controlling the program. Answer yes, they
                   will reclassify wells to allow for only once a year testing,-, it will be up to the Town to
                   enforce the program.

                   Mrs. Stanley Jones stated that the program seemed to be a money saver and not add
                   undo regulations since the regulations involved are already *in effect. NIoved by Mrs.
                   Stanley Jones, second by Nk. St Amour to proceed YAth implementation of the
                   Wellhead Pmtection Pmgram. SO VOTED









                Selectmen - Regular 06-19-95





                                                                           State of New Hampshire                                                                         I' OF.
                                                   DEPARTMENT OF ENVIRONMENTAL SERVICES
                           HDES                            6 Hazen Drive, P.O. Box 95, Concord, NH 03302-0095                                                    0
                                                                    603-271-3503                 FAX 603-271-2867

                                                                          TDD Access: Relay NH 1-800-735-2964




                                                                                    May 26, 1995
                Betsy Ware
                Senior Planner
                Rockingham Planning Commission
                121 Water Street
                Exeter NH 03833


                Subject: Exeter Water Department Wellhead Protection Area Delineations

                Dear Betsy;

                           The Department of Environmental Services is responding to your requests concerning the Phase I
                Wellhead Protection Areas (WHPAs) for Exeter Water Department's groundwater sources. Phase I WHPAs are
                based on available information and represent an approximation of the area from beneath which groundwater is
                drawn to a well. As new infonnation becomes available, Phase I WHPAs may be modified, if the new
                information justifies a modification. Since the original Phase I delineations of the Larry Lane and Skinner
                Spring sources were completed, new information has become available in a report by your commission, "[email protected]
                of Exeter, Water Resource Management and Protection Plan." You requested a review of the report to learn If
                the original Phase I WHPAs for those sources could be modified. We reviewed the report and were unable to
                find justification for modifying the WHPAs. We have modified the Phase I worksheets to include the new report
                as a source of information. Those worksheets are enclosed.


                           Also enclosed are the Phase I WHPA worksheets for Exeter Water Department's Stadium and Gilman
                wells you requested. They are both circles, centered on the wells, with 4000 foot radii. We agree that although
                these wells are currently inactive including their WHPAs in a protection plan ls@ appropriate because the town
                anticipates their reactivation sometime in the future.

                           Guidance for performing a Phase I WHIPA is enclosed for your information. Phase I W14PAs are
                intended to be only an estimate. They are intended for use with management programs consistent with the
                State's program under theGroundwater Protection Act, RSA 485-C. If a more accurate WHIPA is needed then a
                more sophisticated delineation method should be employed. A more sophisticated method would require further
                exploration of the aquifer.

                           Please contact me if you have any questions or would like more information.
                                                                                    @
                                                                                    Sincerely,


                                                                                      udith A. Maloney
                                                                                    Groundwater Protection Bureau
                                                                                      in ere
                                                                                         C 2y
                                                                                      udith A. M@alonev

                lAg%vlib\pds\wellhead\exeter0l jam


        AIR RESOURCES DIV.                     WASTE MANAGEMENT DIV.                       WATER RESOURCES DIV.                     WATER SUPPLY & POLLUTION CONTROL DIV.
        64 No. Main Street                     6 Hazen Drive                               64 No. Main Street                       P.O. Box 95
        P.O. Box 2033                          Concord. N.H. 03301                         P.O. Box 2008                            Concord, N.H. 03302-0095
        Concord. N.H. 03302-2033               Tel. 603-271-2900                           Concord. N.H. 03302-2008                 Tel. 603-271-3503
        Tel, 603,271"1370                      FAX 603-271,2416                            Tel. 603-271-3406                        FAX 603-271-2191
        FAX 603-271-1381                                                                   FAX 603-271-7894


Exeter Water Dept.

Phase 1 Wellhead Protection Area Delineation Guidance				Appendix A



WORKSHEET TO ACCOMPANY A PHASE 1 WHPA DELINEATION   7/93

										Reviewed
										   5/95

Town: Exeter		 Well Name: Lary Lane Well		EPA ID# 0801010-005

Well Type: Overburden    Bedrock     Drilled    Dug    Other(specify)

Population Served: 13,000 people; Town(s) of Exeter

Well Owner Information: Name		Town of Exeter Water Dept.
				Address	10 Front Street
						Exeter, N.H. 03833
				Phone #	(603) 778-0593

Contact Information:	Name		Virgil Harris, Water Plant Supervisor
				Address		

				Phone #

Street Address of Well Location (attach locus map): East end of Lary Lane, Exeter



I. Information obtained to perform delineation:(please check on left if found)


   USGS map: Quadrangle name(s) Exeter, N.H.-Mass. (1:24,000)	Dated 1973
   
   Surficial geology map: name(s)						Dated

   USGS stratified drift aquifer map: names(s) USGS WRI 88-4128	Dated 1990
     ("Geohydrology and Water Quality .... Exeter, Lamprey, and Oyster River Basins,...")
   SGS map: survey name				page(s)			Dated


   WSPCD/WSEB files: (see "other" list below)
	   well log(s)
	   pump test: date        duration
	   maximum yield		 (gpm)
  	   WSEB Sanitary Survey (October 13, 1992)

   Owner/Operators files:
	   well log(s)
	   pump test: date	  duration
	   maximum yield         (gpm)

   WRD/WMB boring logs: none available

   Other (please list): Whitman & Howard, 1986.  Report on Water Supply System for the
        			Town of Exeter, N.H.  Available at WSEB.
				Bradley, E. and Petersen, R.G. 1962, Southeastern Area, N.H. Basic-Data
				Report No. 1. N.H. Water Resources Board.
   Town of Exeter, "Water Resource Management and Protection Plan,"
        by Rockingham Planning Commission for the Exeter Planning

					




                                                  Exeter
         Phase 1 Wellhead Protection Area Delineation Guidance                         Appendix A (Cont'd)
                                               Lary Lane Well

         II. Describe hydrogeologic mapping for upgradient boundary (attach sheet(s) if necessary).

                 Information Utilized: U.S.G.S. topographic mapping


                 Narrative: Due to the low-lying topography and the likelihood that the equifer
		     is confined below a thick layer of marine clay, a 4,000-ft. radius circle was
  		     used to delineate the WHPA.



         III. Complete the following chart and show calculation using the Uniform Flow Equation to derive the
         WHPA boundary down and side gradient of the well. Identify all flow boundaries encountered before
         the calculated distance (attach sheet(s) if necessary).

         Parameter                      Value and Units            Source of Information
         
         Maximum Pumping Rate           Q = 400qpm(=76,800 ft 3/d) Telecomm. w/v. Harris (supt.)(1/22/93)
         
         Transmissivity*                T=

         Hydraulic Gradient             i=

         *Specify Hydraulic Conductivity and saturated thickness used if T is calculated


         Show the calculation performed using the Uniform Flow Equation:







         Describe any flow boundary identified within the calculated boundary:
	    None.



         Comments:






         IV. Attach the delineation and a copy of all information gathered and utilized. Provide a listing of all
         information submitted.








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         GEOHYDROLOGIC AND GROUND-WATER-QUALITY DATA FOR
         STRATIFIED-DRIFT AQUIFTERS IN THE EXETER, LAMPREY,
         AND OYSTER RrVER BASINS,
         SOUTHEASTERN NEW HAMPSHIRE




         By Richard Bridge Moore




         U.S. GEOLOGICAL SURVEY

         Open-File Report 92-95
















         Prepared in cooperation with the
         NEW HAMPS  HIRE DEPARTMENT OF ENVIRONMENTAL SERVICES,
         WATER RESOURCES DIVISION



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                                                         Table 3.-Lithologic logs of wells and borings-Continued

                                                         Depth        DepEh                  Depth
                       Local           Depth             of              to                  to
                       site           drillled           well        refusal                 top   Aquifer
                       number            (ft)            (ft)           (fr)                 (ft)    code             Lithology


                                                                                                   Exeter-Continued



                       EXW 19              23             23                                 0     112mRrN            CLAY GRAY
                                                                                             8     112TILL            TILL     SAND, GRAVEL, CLAY HARDPACKED
                                                                                             23    BEDROCK


                       EXW 20              32             32                                 5     112MRIN            STCL
                                                                                             19    112SRFD            SDGL


                       EXW 21              30             30                                 0     112SRFD            CLAY     HARDPACKED
                                                                                             13    112SRFD            SDGL     SAND AND CLAY SOME GRAVEL
                                                                                             16    112SRFD            SDGL
                                                                                             22    112SRFD            SDGL     SOME CLAY, GRAY


                       EXW 22              24             24                                 0     112SRFO            CLAY     BROWN
                                                                                             10    112SRFD            SDGL     TRACE CLAY, BROWN
                                                                                             18    112TILL            TILL     HARDPAN AND BROWN CLAY


                       ZX.4 23             25             23             2z                  r,    ',12SHFD           SAND     F
                                                                                             10    112MRIN            CLAY     HARD, BROWN, SOME GRAVEL
                                                                                             17    112SRFD            SDGL

                       EXW 24              62             62              --                 0     112mRIN            CLAY     BLUE
                                                                                             55    112SRFD            SDGL
                                                                                             62    BEDROCK


                       EXW     25          28             28             28                  6     112MRIN            CLAY     GRAY, HARD
                                                                                             20    112SRFD            SDGL     SOME CLAY
                                                                                             25    112TILL            TILL     HARDPAN'

                       EXW     26          53             53             53                  4     112MRIN            CLAY
                                                                                             42    112SRFD            SDGL     HARDPACKED GRAVEL

                       EXW     27          30.5           30.5          30.5                 0     112MRIN            CLAY
                       EXW     28          15             75              --                 6     11.2mRIN           CLAY                             Laq
                                                                                             50    112SRFD            SOGL     "GRAVEL"
                                                                                             75    B DROCK

                       EXW     41        114             106           114                   0     112SRFD            SDST     TRACE CLAY
                                                                                             18    112mRIN            CLAY
                                                                                             97    112SRFD            SAND     F-C

                       EXW     42        124             120              --                 0     111SOIL            SOIL


                                                                                             I --    :.eml( IN        CLAY
                                                                                             78    !*.2SRF'D          SGVC     GRAY
                                                                                             82    1125RFD            SAND     F, GRAY
                                                                                             86    112SRFO            SGVC     F-C, GRAY
                                                                                             124   112TILL            TILL


                       EXW 43              16.5           16.5                               --


                       KXW 44            141             12@                                 0     lIS011.            SOIL
                                                                                             1.5   L12SRFD            SAND     F-M, BROWN, SILTY
                                                                                             19    112MRIN            CLAY     WITH SILTY SAND
                                                                                             112   1 12 SHFr)         S D,-. 1. F-m, nROWN
                                                                                             i2b   ::2sRFD            SDGL     F-M, @;RAY
                                                                                             137   112SRFD            SDGL     F, GkAY

                       i.XW i::            1.,                                               0     1 11 so I;.        SOIL
                                                                                             1 .5  11 "SHFI)          SDST     F-M
                                                                                             20    112MRIN            STCL     GRAY
                                                                                             88    '12SRFi)           SDST     WITH CLAY
                                                                                             109   '12SHFU            SDGL     F-C
                                                                                             129   112TILL            TILL






                                                                                                            86








                    Phase 1 Wellhead Protection Area Delineation Guidance                                           Appendix A
                                                                                                                 reviewed
                                                                                                                     5/95
                              WORKSHEET TO ACCOMPANY A PHASE I WHPA DELINEATION


                    Town: Exeter                              Well Name: Skinner Springs            EPA ID# 0801010-004
                                                                                           
                    Well Type: Overburden        Bedrock       Drilled      Dug      Other(specify)

                    Population Served:          people; Town(s)of
                    
                    Well Owner Information:    Name            see worksheet for -005
                                               Address

                                               Phone #
                   
                    Contact Information:       Name         Virgil Harris, Water Plant Supervisor
                                               Address

                                               Phone#

                    Street Address of Well Location (attach focus map):



                    I. Information obtained to perform delineation: (please check on left if found)


                        USGS map: Quadrangle name(s)  Exeter, NH      1:24000                   Dated 1973

                        Surficial geology map: name(s)                                          Dated

                        USGS stratified drift aquifer map:name(s) USGS WRI 88-4128              Dated 1990
                            (Geohydrology, ...Exeter, Lamprey, and Oyster River Basin,...")
                        SCS map: survey name                                  page(s)           Dated


                        WSPCD/WSEB files:
                           well log(s)
                           pump test: date                   duration
                           maximum yield                   (gpm)


                        Owner/Operators files:
                           well log(s)
                           pump test: date                   duration
                           maximum yield                   (gpm)

                        WRD/WIVIB boring logs:
                                                                                                                     
                        Other (please list): Town of Exeter, "Water Resource Management and
							   Protection Plan," by Rockingham Planning Commission
							   for the Exeter Planning Board,    (continued on reverse)
							   Aug. 1993.









               Phase 1 Wellhead Protection Area Delineation Guidance                         Appendix A (cont'd)



               II. Describe hydrogeologic mapping for upgradient boundary (attach sheet(s) if necessary).

                      Information Utilized: This is a spring, confined condition.



                      Narrative:






               III. Complete the following chart and show calculation using the Uniform Flow Equation to derive the
               WHPA boundary down and side gradient of the well. Identify all flow boundaries encountered before
               the calculated distance (attach sheet(s) if necessary).

               Parameter                     Value and Units             Source of Inforrnation

               Maximum Pumping Rate          Q= 69 gpm                   WSEB database
             
               Transmissivity*               T=

               Hydraulic Gradient            i=

               *Specify Hydraulic Conductivity and saturated thickness used if T is calculated


               Show the calculation performed using the Uniform Flow Equation:
                               Because this is a "spring" it was delineated
				as a 4000 foot circle.  This is the
				radius called for under the Phase I
				program for confined aquifer sources
				such as this.

               Describe any flow boundary identified within the calculated boundary:




               Comments:






               IV. Attach the delineation and a copy of all information gathered and utilized. Provide a listing of all
               information submitted.


APPENDIX A
WORKSHEET FOR BEDROCK AND CONFINED OVERBURDEN SOURCES

5/95

Step 1:  Complete Background Information    Fill in the following information:


EPA System 7-digit ID #:  0801010		3-Digit Source ID #:  006/007

System Name:  Exeter Water Dept.				Town Location:  Exeter

Source Name:  Stadium/Gilman Wells				   Population Served:  13,000 people

Street address of well location:

Well Owner Information; Name:     Town of Exeter Water Dept.
				Address:  10 Front Street
					    Exeter NH 03833
				Phone #:  (603)778-0593  Virgil Harris

Contact Information:    Name:     Betsy Ware, Rockingham Planning Commission
			      Address:  121 Water St
					    Exeter  03833
				Phone #:  778-0885


Step 2: Identify Location on Map


	USGS Topographic Map name:  Exeter			Date:

	Well location confirmed by:
	  These wells are in a confined aquifer (USGS WRIR 88-4128)

Step 3: Identify Maximum 24-Hour Withdrawal Volume

				(The Phase I WHPA will be valid only when the well is operated at or below this volume.)



	*If withdrawal records are available then show calculations below.
				500 gpm ea. According to "Report on Gravel Packed
		well water supply, Exeter NH" by Whitman & Howard, February
		p.-3-   28 feet of clay over the waterbearing gravel..."   1963



						Stadium:		
MAXIMUM 24-HOUR WITHDRAWAL VOLUME = 720,000 gallons
						720,000
(step e continued on reverse side)	Gilman:








            If withdrawal records are not available then complete the following chart.

                  Column I                       Column 2                         Column 3                        Column 4
                  Use Type                Daily Demand per Unit                                            Daily Demand Volume
               (from table one)             (from table one)                  Number of Units              (Column 2 x Column 3)

                                                                                                                             gallons

                                                                                                           +                 gallons

                                                                                                           +                 gallons



                                                                         MAXIMUM 24-HOUR WITHDRAWAL VOLUME =                 gallons
                                                                                                             (Column 4 Total)





     Step 4: Identify WHPA Radius

             Maximum 24-hour withdrawal volume from step 3 =
             Corresponding WHPA radius from table two = 4000 feet = WHPA RADIUS
                                                        4000           



     Step 5: Draw the WHPA

             Draw a circle around the well with a radius equal to the WHPA radius from s 3.




    Step 6: Subrnit Delineation to NH DES for Review

        Send delineation and copies of all maps and data utilized to:    NH Wellhead Protection Program
                                                                         Groundwater Protection Bureau
                                                                         Department of Environmental Services
                                                                         PO Box 95
                                                                         Concord NH 03301




        Worksheeqt completed by: 					Date:  5-8-95





                                        Rockingham
                                        Planning                                    121 Water Street, Exeter, N.H. 03833
                                        Commission                                  603-778-0885       Fax 603-778-9183




                     Exeter Wellhead Project


                     The Town of Exeter will be holding a public informational meeting on developing a wellhead
                     protection program to protect its municipal water supplies. This meeting will be held on

                                                       Tuesday, June 27, 1995
                                                            at 7:30 pm.
                                                         Exeter Town Offices
                                                   Nowak Room (located on the second floor)



                     The program will be established to protect the Skinner Springs well, located beside Route 101 in
                     Stratham, the Larry's Lane well, located at the end of Larry's Lane and the Gilman and Stadium
                     wells, located near Gilman Park in Exeter. In conjunction with this wellhead protection program,
                     the Town of Exeter has delineated its wellhead protection areas, will be developing a monitoring
                     program for potential contamination sources, and will be seeking a groundwater reclassification
                     for its well water. For more information please contact Betsy Wareof the Rockingham Planning
                     Commission at 778-0885.







Atkinson Brentwood Danville East Kingston Epping Exeter Fremont Greenland Hampstead Hampton Hampton Falls Kensington Kingston New Castle
     Newfields Newington Newton North Hampton Plaistow Portsmouth Rye Salem Sundown Seabrook South Hampton Stratham Windham















       


                                                                                                   M M M M M = M M = -=--- M IM
                                                                                              Town of Exeter
                                             Wellhead Protection Areas (WPAs)









                                                                                                                                                                                                          kinner
                                                                                                                                                                                                          Springs
                                                                                                                                                                                                                   ell























                                                                                                          Stadium
                                                                                                             Well


                                                                                                  a
                                                                                         Gi
                                                                                                W                                                                                                                                                                                           X.









                                                                              Larry Lan e
                                                                                        W e lal













                                                                                                                                                                                          Exeter Source:
                                                                                                                                                                                          -Pr-ep          f                         -cel
                                                                                                                                                                                          for                                           formed
                                                                                                                                                                                               the 7,                               pqr-M-p
                                                                                                                                                                                          by the Rockingham Planning Commission.

                                                                                                                                                                                          Strathom Source:

                                                                                                                                                                                          Pre
                                                                                                                                                                                           , parationof a Digitizoed Tax Parcel Map, forathepT            Iwo at
                                                                                                                                                                                          S rat4orq,      H. (,3 perf rmed by the Rockin         9h m   lanning
                                                                                                                                                                                          Commission.
                                                                                                                                                                                          Updated in June 1994 to encompass changes through 1993.


                                                                         Legend


                                                                            ocation of tell







                                                                           t,000 ft. Protection Zone
                                                        Ni
                                                                                                                                                                                          rhis ma
                                                                                                                                                                                               Ho pp wqs funded in part by a grant from the Office of State P.Ionning,
                                                                                                                                                                                                  m   ql,r      :to ItrrogtoomAAls Aouthorized by the National Oceanic and'
                                                                                                                                                                                                   e,     e 'Pq                            d
                                                                                  rcol Boondaries                                                                                         Atmo,ph 1c Admini fro ion         N           war   Number NA37020277.
                                                                               P"





                                                                                                                                                                                                                                         P       4 by the
                                                                                                                           S c a I e    1   1 8 0 0 0                                                                           Rocki  3zh       ,    Cominhion
                                                                                                                                                                                                                                               Io
                                                                                                                                                                                                                                        no                    A
                                                                                                                     1     n c h = 15 0 0 f e e t


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         Page 2~'0 - The Exeter News-Letter'. June 27, 1995:
                                                                                                                                                     ~4~. Sam, ~0qS



                                                                                                                                                          SEABROOK                  En
                                                                                                                                                        Seabrook will cel~ebra
                                                                                                                                                        Saturday. July 1. f~r~o~i
                                                                                                                                                          Twenty      percent       of
                                                                                                                                                        given to     the SID~qS
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                                                                                                                                                        ~ce~eds will    go to the
                                                                                                                                                             -old Stephen ~8qY~.
                                                                                                                                                        year
                                                                                                                                                        was critically injure
                                                                                                                                   ~"~Z~I                  the parking- lot of
                                                                                                                                   If                   and remains In s
                                                                                                                                                        Children's Hospital,
                                                                                                                                                          Festivities will I~.
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                                 T6~48qWN OF EXETER, NEW HAMPSHIRE                                                                               Iva
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                                     ~q3~q:~q.   ~q9 Wet; ~4ql~qo~qe~qj~2q@t~qe~0qd at th~qe`~2q@~qn~8qd~q-~q'~4qj~6q;~36qf~36qt~84q@ ~2q1~4q@~q- ~q:~6qi~8qn th~qe~q-~q,~q27.~q:                               ~04qW~qoon to be forwarded
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 




                                        Rockingham
                                        Planning,                                                       121 Water Street, Exeter, N.H. 03833
                                        Commission                                                      603-778-0885                  Fax 603-778-9183




                                                                 Exeter Wellhead PrQject
                                                                     Tuesday, June 27, 1995
                                                                              at 7:30 pm.
                                                                        Exeter Town Offices
                                                       Nowak Room ( located on the second noor)

                                                                                 Aj!enda


                                                                    1. Introduction of Officials


                                                             George Olson, Exeter Town Manager
                                                       Keith Noyes, Exeter Director of Public Works
                                               Brian Comeau, Assistant Fire Chief/ExeterHealth Officer
                                       Sarah Pillsbury, N. H. Department of Environmental Services (DES)
                                                        Water Supply and Pollution Control Division
                                                 Betsy Ware, Rockingham Planning Comnuisslon (R-PC)


                                                              111. Wellhead Protection Program

                                                                 A@ Location of Municipal Wells
                                                Skinner Springs well, located beside Route 10 1 in Stratharr@
                                                    Larry's Lane well, located at the end of Larry's Lane
                                                    Gilman and Stadium wells, located near Gilman Park

                                                 B. Delineation of Wellhead Protection Areas (WHPAs)

                                              C. Identification of Potential Contan-iination Sources (PCSs)



                                                              M. Groundwater Reclassification


                                      A- Reclassification of Exeter Groundwater Resources from GB to GAA
                                                                   B. Conduct BNV Inspections
                                                   C. Maintain PCS Inventory and Monitoring Program

                                                                   IV. Questions and Answers


         Atkinson  Brentwood.- Danville -East Kingston -Epping -Exeter -Fremont -Greenland -Hampstead -Hampton - H a mpton Fal Is - Kensington -Kingston -New CaSLIC
                Newfields - Newington - Newton - North Hampton - Plaistow - Portsmouth - Rye - Salcm - Sandown - Seabrook - South Hampton - Stratharn - Windharn





       Beneath your feet, Beneath the ground................
   Groundwater is flowing through soil particles and bedrock fractures



                                 
 THIS IS YOUR SOURCE OF DRINKING WATER
 
         HELP PROTECT IT

Don't......
                                            Dump any chemicals down the drain
                                            or on the ground. Examples: Waste oil,
                                            Paints, Thinners, Solvents, Pesticides
                                            Solution: Make use of your Town's
                                            Household Hazardous Waste
                                            Collection Day


Do.......                     Follow package directions on any pesticides

                                                           




Do.......

  Keep an eye on your                                                                  
  underground fuel storage tanks.
  An unexplained drop in level
  may mean a leak.                             
                                                                                                                                              
                                                             






      ENVIRONMENTAL                                                                     NEW HAMPSHIRE
                                                                                         DEPARTMENT OF
                                                                               Environmental
                                                                                          Services
                                                                       6 Hazen Drive, Con-cord, NH 03301

       NHDES Technical Bulletin            WSPCD-GPB-1992-2

                        LOCAL RECLASSIFICATION OF GROUNDWATER
                           TO IMPLEMENT PROTECTION PROGRAMS:

                                         A TEN STEP PROCESS


      STEP ONE : DELINEATE AREA TO PROTECT- (i.e. wellhead protection area (GAA) or other area of locally important
      groundwater (GAl).) The wellhead protection area is delineated either by the local entity requesting reclassification or by
      the Department of Environmental Services (DES) with materials furnished by the local entity. The area is delineated by
      using simple methodolgy found in DES' "Phase I Wellhead Protection Area Guidance- or other superior methodology.

      STEPTWO: INVENTORY POTENTIAL CONTAMINATION SOURCES (PCSs) LOCATED IN DELINEATED AREA
      The inventory is performed by the local entity seeking reclassification. See DES' "Developing a Local Inventory of
      Potential Contamination Sources" guidance for more information.

      STEPTHREE: HOLD AN INFORMATIONAL MEETING -The purpose of this meeting is to inform the public of your
      intentions to implement a protection program.


      STEP FOUR: PERFORM INVENTORY INSPECTIONS OF ALL PCSs IN AREA PROPOSED FOR RECL ASSIFICA TION -
      Performed by the local entity seeking reclassification, the purpose of inventory inspections is to insure that all PCSs in the
      inventory use.,,harde, store, or dispose of regulated substances. It they do not, they should be taken off the inventory. This
      is not an inspection for compliance with Err,/-Ws 421 , Management Practices for Potential Contamination Sources, but
      instead is a short inspection to verify the use and to estimate the quantities of hazardous substances present.

      STEP FIVE: PREPARE AN INVENTORY REPORT - Prepared by the local entity seekFng reclassification, this report
      provides owner, hazardous substance, and locational information on each PCS. It also documents that an inventory
      inspection occurred and provides a map with the PCSs located and identified on 4.

      STEP SIX: PREPARE A PCS MANAGEMENT PROGRAM - Prepared by the local entity seeking reclassification, this
      program identifies the process that will be utilized for: updating the inventory. notifying PCSs (at intervals not to exceed
      three years), and performing inspections for compliance with Env-Ws 421. In addition it provides names and addresses of
      all land owners in ft area to be reclassified and a list of all facilities which have or would need to obtain release detection
      permits. It also includes an assessment of the local entitie's ability to irriplement and maintain the protection program
      authorized by reclassification.

      STEP SEVEN: SUBMIT A REQUEST TO RECLASSIFY GROUNDWATER TO THE DEPARTMENT OFENVIRONMENT-
      AL SERVICES- This request, submitted by the local entity requesting reclassification, is accomplished by filling out a
      reclassification request form and sending it to DES. It should be accompanied by: the delineation of the area the local
      entity intends to protect, a brief description of the informational meeting that was held, the inventory report, and the PCS
      management program.

      STEP EIGHT: N077FY AFFECTED PARTIES AND HOLD A PUBLIC HEARING - After acknowledging receipt of the
      reclassification request to the local entity, DES must notify the town or city clerk of all affected municipalities and all land
      holders.of record of the request. In addition, DES must hold a public hearing.
                                                                      OEn;virc


















      STEP NINE: APPROVE OR DENY RECLASSIFICATION REQUEST- The Commissioner of DES grants or denies
      reclassification requests . If the request is denied, DES must notify the local entity of the reasons for dend.










                        List of Properties within the Gilman, Larry's Lane, Skinner Springs and Stadium
                                                   Wellhead Protection Areas (WHPAs)




                  Map       Block   Lot               Property Owner


                  08-04             44                Lee's Mobile Park
                  08-04             52-59, inc.
                  08-04             59-83, inc.       all residential except for Town of Exeter Cemetery
                  08-04             90-152,inc.
                  08-04             145               Town of Exeter Recreation Land

                  08-04A                              Exeter Villa

                  08-12 26          3-10, inc.        all residential

                  08-16 09          3-6, inc.         all residential except for funeral home (McDonough, 2 Lincoln St)
                  08-16 10          11-23, inc.       all residential
                  08-16 11          1-11, inc.        all residential
                  08-16 12          1-5, inc.         all residential except for Exeter Jr.Sr. High School (38 Linden St)

                  09-02             1-34, inc.        all businesses/land under current use

                  09-03             2-3               Town of Exeter/McClintock -retail shops
                  09-03             26-3 1, inc.      PEA/Larry Lane well

                  09-04             2-12, inc.        all residential and Phillips Exeter Academy (PEA)
                  09-04             13-32, inc.       all residential

                  09-07   1         1-6, inc.

                  09-07   2         1-19, inc.        all residential

                  09-07   3         1-12, inc.        all residential

                  09-07   4         1-8, inc.         all residential except for (8) REMax (134 Portsmouth Ave.)

                  09-09   9         1                 PEA

                  09-09   10        1-15 inc.         all residential except for one church and post office

                  09-09   11        1-14 inc.         all residential except for one church











                    Exeter Wellhead Plan
                    Property Owners in VVIIPA
                    Page 2.

                    Map Block Lot                        Property Owner
                    09-10 7            22-29 inc.        two retail/food mart, remainder residential


                    09-10     10       5-15 inc.         residential/one office


                    09-10     11       1-9 inc.          all residential-multi-family and single-family

                    09-10     12       5-14 ine.         condos/residential


                    09-10     15       1- 17 inc.        all residential


                    09-10     16       1- 16 inc.        all residential


                    09-10     17       1-5 inc.          all residential


                    09-10     18       1 and 2           all residential


                    09-10     19       1-7 inc.          all residential


                    09-10     20       1-13 inc.         all residential except for auto garage (Carmen)

                    09-10     21       1-30 inc.         all residential except for tovvring co/auto repair

                    09-10     22       1-7 inc.          all residential except for food market

                    09-10     23       1-14 inc.         all residential except for nursing home

                    09-11     1        1-6, inc.         all residential or current use land

                    09-11     2        1-11, inc.        medical offices, condos, residential

                    09-11     3        1-17, inc.        all residential, land or Town of Exeter

                    09-11     4        1-2, inc.         all residential

                    09-11     5        1-3, inc.         all residential

                    09-11     6        1-5, inc.         all residential

                    09-11     7        1- 12, inc.       all residential










                 Exeter Wellhead Plan
                 Property Owners in VIHPA
                 Page 3.



                 Map      Block Lot                  Property Owner

                 09-11 8            1-4, inc.        all residential

                 09-11    9         1-20, inc.       all residential

                 09-11    10        1-3, inc.        all residential

                 09-11    11        1-4, inc.        all residential

                 09-12    1         1-19, inc.       all residential and the Town of Exeter

                 09-12    2         1-11, inc.       all residential and land

                 09-12    3         1-5, inc.        all residential and land


                 09-13    1         1                St. Michael Catholic Church


                 09-13    2         1-3, inc.        residential and church

                 69-13    3         1-17, inc.       residential, churchTown of Exeter, machine shop, tire warehouse

                 09-13    4         1-30, inc.       PEA and residential

                 09-13    5         1-14, inc.       PEA and residential

                 09-13    6         1-11, inc.       Exeter Methodist Church and residential

                 09-13    7         1-5, inc.        residential and land

                 09-13    8         1- 1 5,inc.      all residential

                 09-13    10        14,inc.          all residential

                 09-14    1         1-10,inc.        all residential and PEA


                  09-14   2         1-14 inc.        all residential











                     Exeter Wellhead/6/6/95
                     Lots within WIHPAs
                     Page 4.



                     Map Block Lot                       Property Owner
                     09-15     1        1-23, inc.       all residential

                     09-15     2        1-23, inc.       all residential

                     09-15     3        1-6, inc.        all residential

                     09-15     4        1-6, inc.        residential and the First Baptist Church

                     09-15     5        1-6, inc.        all residential


                     09-15              12               residential
                                        3-5 Inc.         all residential


                     09-16     1        1-3, inc.        all residential

                     09-16     2        1-3, inc.        all residential

                     09-16     3        1-3, inc.        all residential

                     09-16     4        1-6, inc.        all residential

                     09-16     6        1-6, inc.        all residential

                     09-16     7        1-7, inc.        residential and offices

                     09-16     9        1-10, inc.       all residential

                     09-16     10       1-5, inc.        all residential

                     09-17              1-14, inc.       all residential- Conti subdivision

                     09-17     1        1-2, inc.        all residential

                     09-17     2        1-12, inc.       all residential - Conti subdivision










                Exeter WeUhead/6/6/95
                Lots within WBPAs
                Page 5.



                Map Block Lot                  Property Owner


                10-01           1-14, inc.     residential and land

                10-03           29-36, inc.    residential, multi-fanffly, offices

                10-03           44-45, inc.    all residential

                12-2            12-33.001, inc. campground, current use, Town of Exetersome residential

                13-1            1-5, inc.      all residential and current use


                13-2            1              residential











                 June 1995- Draft


                     Non-Rcsidential Uses within the Skinner Springs/Gilman/Stadium and Lary's Lane
                                             Wellhead Protection Areas (WHPAs)

                 Map 09-02-002        John W. Flynn, Tr. 94 Portsmouth Ave, Exeter (Auto garage/tire sales)

                 Map 09-02-008        Exeter Health Resources, Inc. 10 Buzzell Ave. Exeter (medical bldg.)

                 Map 09-02-022        Laurence Foss, 30 Bunker Hill Ave. Stratharn 03885 (car dealership on
                                      Portsmouth Ave. in Exeter)

                 Map 09-02-023        Jerrold DuPont, P.O. Box 613, Ogunquit, ME. 03907 ( Toyota dealership
                                      and service on Portsmouth Ave.)

                 Map 09-02-24         RVS, Inc. 137 Portsmouth Ave, Exeter (Motel and restaurant)

                 Map 09-02-026/027    King Chevrolet and Olds Co. Kenn King Ent. Co., Inc.
                                      P. 0. Box 216, Stratharn, New Hampshire 03885 (auto sales and service
                                      on Portsmouth Ave in Exeter)

                 Map 09-02-16-1       Tyco Laboratories- One Tyco Park@ Exeter, N.H. 03833

                 Map 09-02-17         Tyco, Laboratories (underground storage tank-gasoline)

                 ,Map 09-02-18        Carl Rogalski, Fleet Investment Service, 3 Pleasant St. Portsmouth
                                      (Vacant land/current use)

                 Map 09-02-19         Exeter/Hampton Electric Co. 14 Drinkwater Rd. Kensington NH 03833
                                      (Noted in VRvfPP as having over 60 regulated substances on Epping Rd)

                 Map 09-02-21         GTE Products Corp./Osram Sylvania 131 Portsmouth Ave, Exeter
                                      (Noted in VVMPP as having regulated substances and under SARA)

                 Map 09-02-28         McFarland Realty Trust, 151 Portsmouth Ave, Exeter
                                      (Auto repair and sales- on State RCRA generator list)

                 Map 09-02-34         Jon Wentworth, Wentworth Motors, 140 Portsmouth Ave. Exeter
                                      (Auto sales and service)

                 Map 09-03-30/31      Phillips Exeter Academy, Main Street, Exeter
                 Map 09-03-28         (PEA operating garage- on State RCRA generator fist)









             Non-residential Uses/Wellhead
             Town of Exeter
             Page 2.


             Map 09-03-          MY Robert McClintock, 12 Sentry Oak Lane, Hilton Head Island
                                 South Carolina 29926
                                 (115 Court Street- retail shops)

             Map 09-07-04-008    Ben and Joan D'Agostino, RE Max Preference R.E. 134 Portsmouth Ave.,
                                 Exeter, N.H. 03833 (real estate office/former gas station- pumps still in
                                 ground)

             Map 09-07-01-006    Precision Media Corp. P. 0. Box 1540, Exeter, N. H. (Radio station)

             Map 09-09-10-1      Gorham Hall Trust P.O. Box 990, Exeter N.H.
                                 (Offices)

             Map 09-09-10-14     Peter Sawyer, 50 Moulton Ridge Rd. Kensington, N. H. 03 83 3
                                 (Offices)

             Map 09-09-10-15     Random Actions Inc.B-2 Riveredge, 117 Bow St. Portsmouth
                                 (Offices)

             Map 09-10-7-29      Nicolleta Pappas, 5 67 Congress St. Portland, ME 04 101
                                 (Retail store- 2 Portsmouth Ave)

             Map 09-10-7-29      VSH Realty Inc. 77 Dedham St. Canton, Ma.'02021
                                 (Food mart at 6 Portsmouth Ave)

             Map 09-10-10-14     James and Nancy Moran, 26 Hampton Rd. Exeter, N.H. 03833
                                 (Office at One Portsmouth Ave.)

             Map 9-10-15-1       Water St. Realty Tr. 42 Water St. Exeter N.H. 03 8 3 3 (restaurant)

             Map 9-10-15-2       Christy's Realty, 22 Christy's Drive, Brockton, Ma. 02401
                                 (Store/market- formerly a gas station- tank removed 1994)

             Map 9-10-15-6       Janice Jackson, Blake Road, Epping, N.H. 03042 (Office)

             Map 9-10-15-17      Christie Ann Jones, SPA Trust, c/o Pat Rose Tischler Gro up, P.O. Box
                                 4489 Portsmouth, N. H. 03802 (retail stores)

             Map 9-10-16-1       Getty Petroleum, Inc. 125 Jerico Turnpike, Jerico, N.Y. 11753
                                 (Bow St. gas station- on State RCRA generator list)










               Non-Residential Uses/Wellhead
               Town of Exeter
               Page 3.


               Map 9-10-16-4       Town of Exeter Police Complex/ Court and Down Streets
                                   (Underground storage tanks- 10,000 gallons-gasoline)

               Map 9-10-20-3       Gerald Carmen, 1667 Elm St -Suite 4, Manchester, N.H. 03 101
                                   (Commercial garage at One Franklin St.-underground tank)

               Map 9-10-20-3       Robert E. Spoerl, 22 Exeter Rd. So. Hampton, N.H. 03827
                                   (Retail shops located at 8 Clifford St.)

               Map 9-10-2 1 - 10   (Lots I to 8) Long Block- Franklin St. all offices

               Map 9-10-21-11      Harold Lampert, 20 Franklin- Street, Exeter, N.H. 03833
                                   (Automotive sales and repair/towing co.)

               Map 9-10-22-3       Robert and Alma Hall, 27 Hall Place, Exeter, N.H. 03833
                                   (39 -41 High Street Food mart)

               Map 9-10-23-1       Eventide Home Inc. 81 High Street, Exeter, N. H. 03833
                                   (Medical- nursing home- On State RCRA Generator list)

               Map 9-13-03-15      Michael Quigley Sr. 95 Court St. Exeter, N. H. 03833
                                   (Abandoned mach@ine shop-)

               Map 9-13-03-16      Lionel LaBonte, 95 Tidewater Farm, Stratham, N. H. 03885
                                   (93 Court Street - warehouse)










             Non-Residential Uses/Wellhead
             Town of Exeter
             Page 4.


             Non-Residential Uses in the Town of Stratharn, New Hampshire (Skinner Springs WHPA)

             May/ Parcel          Name and Address of Owner/Use



             Map I/ Lot 4         Lionel LaBonte, Stratharn Tire, 17 Portsmouth Ave, Stratharn, New
                                  Hampshire 03885

             Map 7/ Lot IS        Ralph Pynn, Undercar Specialist, 12 Portsmouth Ave, Stratham, New
                                  Hampshire, 03885

             Map 7/ Lot 7         Heirs of Peg Shaw, c/o Charter Gas, 9 Portsmouth Ave. Stratharn, New
                                  Hampshire 03885

             Map 7/Lot 8          David Engel, 23 Portsmouth Ave, Stratharn, New Hampshire 03885
                                  (Antique Repair co.- paints, furniture, stripping)

             Map 7/ Lot 6-1       Rockingham County News, 7 Portsmouth Ave, Stratham, New Hampshire
                                  03885 (newspaper printing co.)

             Map 7/Lot 74         Stephen Bassett, Exeter Veterinary Hospital 10 Stratharn Heights Road,
                                  Stratharr@ New Hampshire 03885

             Map 7/ Lot           Jeffrey Hurlbert, Hurlbert Nissan One Portsmouth Ave, Strathan-@ New
                                  Hampshire 03885














                       D
                                      TOWN OF EXETER
            0
            -4                IL                10FRONTSTREET EXETER, NH03&k3-2792 (603)778-0591

                  41AR, APXI

                  Mr.      n Wool, Chairman
                  Stratharn Board of Selectmen
                  10 Bunker 10 Avenue
                  Stratham, New Hampshire 03885

                  RE:    Exeter Wellhead Protection Program


                  D"
                           @o 0 1.-



                  As you may be aware, the Town of Exeter is undertaking a wellhead protection program in
                  accordance with RSA 485-C. This program, similar to the program adopted several years ago by
                  the Town of Stratharn to protect their groundwater resources, will protect Exeter's groundwater.
                  Exeter's residents are almost entirely dependent on groundwater resources for their drinking
                  water and municipal officials believe that the Town of Exeter should take every step to protect its
                  water supplies.

                  One of Exeter's wells, Skinner Springs well, is located in Exeter. Due to its location along Route
                  ,10 1 and its 4,000 foot wellhead protection area (WIPA), a number of businesses that are
                  Potential Contamination Sources (PCSs) are in Stratham. These PCSs will require monitoring
                  visits once every three years, at an absolute minimum. Due to this situation, the Town of Exeter
                  is requesting that the inspection. reports prepared by the Town of Stratham for properties located
                  within the Skinner Springs WHPA be shared with the Town of Exeter. In exchange for these
                  reports, the Town of Exeter will provide inspection reports for proper-ties in Exeter which are
                  located within Stratham's WIHPAs.


                  Upon my return from vacation on July 17, 1995,. 1 would Eke to discuss any reciprocal
                  arrangements for WBPA inspections that could be made between our respective communities. I
                  have attached a copy of a map of the Town of Exeter with the V4HPAs. I have also attached a
                  fist of the properties, writh map and parcel numbers, and name and address of owners for your
                  review. I thank you for your attention to this matter and will contact you after July 17,1995.


                  Sincerely,



                  Geo e Ols
                  Town Mann er
                             ag





                                    TOWN OF EXETER

          C                 CL               10 FRONT STREET EXETER, NH 03833-2792 (603) 778-0591
           Ot





                July 3, 1995



                Mr. Scott Lowell
                Chairman, Board of Selectmen
                95 Amesbury Road
                Kensington, New Hampshire 03833

                RE:     Exeter Wellhead Protection Program



                Dear Mr. Lowell:



                As you may be aware, the Town of Exeter is undertaking a wellhead protection program in
                accordance with RSA 485.-C. Th.is p   rogram, similar those adopted by other area commur@ties, is
                aimed at protecting groundwater resources. Exeter's residents are almost entirely dependent on
                              resources for their drinking water and municipal officials believe that the Town of
                Exeter should take every step to protect its water supplies.

                One of Exeter's wells, Larry Lane well, is located in the southern portion of Exeter. Due to its
                location along Route 150 and its 4,000 foot wellhead protection area (VaIPA), a number of
                properties within the Larry Lane wellhead are located in Kensington. While none have been
                identified as Potential Contamination Sources ( PCSs) (the bulk of this property is undeveloped
                farm lands and wetlands) the Town of Exeter would like an opportunity to conduct monitoring
                visits should a new business, which uses regulated substances, begin operation in this zone.

                Upon my return from vacation on July 17, 1995, 1 would like to discuss any arrangements for
                WBPA inspections. I have attached a copy of a map of the Town of Exeter with the WHPAS. I
                thank you for your attention to tEs matter and will contact you after July 17,1995.


                Sincerely,
                !@@rgels..
                Town Manager





                          Rockingham
                          Planning                                121 Water Street, Exeter, N.H. 03833
                          Commission                              603-778-0885       Fax 603-778-9183


               MEM TO:     Keith Noyes, Exeter Director of Public Works

               F'ROM:      Betsy Ware, Rockingham Planning Commission

               DATE:       May 2, 1995

               SUBJECT:    Management Plan Options for Wellhead Protection Program
                           for the Town of Exeter



               Leading up to the management plan for Exeter's Wellhead Protection Program, the
               following tasks will have been completed:

               1.    Wellhead Protection Areas (WHPAs) will have been delineated for the Town's
                     municipal water wells.  I have attached the request made by the RPC to the
                     Water Supply and Pollution control Division of the Department of
                     Environmental Services (DES)      They have confirmed that they have the
                     information that they need to delineate these areas and anticipate that
                     the work will be completed within the next three weeks.
                                                                                                         N
               2.    An initial list of Potential Contamination Sources I 'PCSs) within the WHPAs
                     will have to be compiled. This information was included on Maps 9, 9A and
                     9B and in Appendices C, D. E, F, and G--of Exeter's 1993 Water Resource
                     Management and Protection Plan.       once the wellhead protection areas
                     (WHPA's) are determined by DES, we can review and update these lists to
                     see which PCSs fall within the wellhead protection areas.

               3.    The Town and the RPC will conduct inventory inspections of PCSs identified
                     in the initial list in order to determine which establishments are active
                     and use regulated substances in more than household quantities - thus
                     qualifying them for inclusion in the Wellhead Protection Program's
                     management plan.

               4.    Based upon the inventory inspections described above, a master list of
                     PCSs will be developed.    The PCSs identified on the master list will be
                     subject to the Wellhead Protection Program's management plan.

               There are four management plan options for Exeter's Wellhead Protection Program.
               These options and their pros and cons are described in detail below. This memo
               concludes with a recommendation as to which management plan option to pursue and
               an assessment of costs to be incurred.


















       Atkinson- Brentwood - Danville- East Kingston. Epping- Exeter- Fremont - Greenland - Hampstead - Hampton- Hampton Falls -Kensington -Kingston - New Castle
            Newfields . Newington - Newton - North Hampton - Plaistow - Portsmouth - Rye - Salem - Sandown - Seabrook - South Hampton - Stratham - W,  indham










             K. Noyes/Town of Exeter
             Wellhead Protection Program
             Page 2.

                                                  Option #1

             I*    Notify PCS owners

             2.    Maintain PCS inventory

             The Town would send notice to all PCS owners, alerting them that their business/
             use is located within a contributing area of a municipal water well. The notice
             would inform the owners of Exeter's Wellhead Protection Program, the need to
             comply with the State's Best Management Practices (BMP) administrative rules, and
             would include the BMP rules as well as a groundwater protection educational
             flyer.

             The Town would also distribute the BMP rules to all new PCS owners which move to
             Exeter.   This step would occur upon their application for a Certificate of
             occupancy.

             Pros: The cost associated with this option are very low. The only costs involved
             would be in the preparation of notice letters, BMP rules, mailings, and the on-
             going upkeep of the PCS inventory. The Town would not have to absorb the cost
             of having BMP compliance inspections as part of the management plan.

             Cons: This option is not a pro-active groundwater protection strategy.      The Town
             would have no assurance that PCS owners were complying with the State's BMP
             rules. Also, the Town could not apply to the State for Phase II & V waivers for
             the required water quality testing of its municipal wells,


                                                  Option #2

             1.    Notify PCS owners

             2.    Adopt a municipal health ordinance

             3.    Conduct BMP compliance inspections when deemed necessary

             4.    Maintain PCS inventory

             The Town would take the same   steps outlined under Option #1, however, the Town
             would take the additional step of adopting a municipal health ordinance. This
             ordinance would be written in such a way as to allow Exeter's Health Officer (or
             a duly appointed designee) to inspect a PCS site if a problem is suspected. The
             ordinance could also include other provisions, such as septic system maintenance
             and replacement standards for those residences and businesses located outside of
             the municipal sewer service area,

             Pros: This is a relatively low cost option. The costs involved would be the same
            .as outlined under option #1, along with the notice, copy and staff time costs
             which would be incurred in the preparation of a health ordinance. This option
             would provide PCS owners with BMP information and reserve the Town's right. to
             inspect their site if a problem is suspected, thus provided an added degree of
             assurance that BmPs are being complied with. The City would not have to absorb
             the cost of having regular BMP compliance inspections as part of the management
             plan. Additional costs would be incurred only when a problem is suspected and
             an inspection takes place.

                                                       2









              Cons: The same drawbacks outlined under option #1 apply here as well.         Once
              again, EMP compliance is assumed but not verified. By reserving the right to
              inspect for BMP compliance, but not doing so unless a problem exists or is
              suspected, the Town would be in a reactive posture. Also, PCS owners may view
              this option as unfair in that it allows the Town to "single out" a business and
              treat them differently than other businesses.

              Exeter could not apply the provisions of the health ordinance to the PCSs located
              outside of the Town boundaries. It is unlikely that another municipality would
              grant Exeter the discretionary right to inspect the PCSs located in their
              community.

              Lastly, once again the Town could not apply to the State for Phase II & V waivers
              for the required water quality testing of its municipal wells.

                                                  Option #3


              1.    Reclassify the Town's groundwater resources to GAl

              2.    Notify PCS owners and all Town residents

              3.    Conduct BMP compliance inspections

              4.    Maintain PCS inventory

              Regarding the first task, the Town would apply to the DES Groundwater Protection
              Bureau to have its groundwater resources reclassified to GA1. Under the 1991
              Groundwater Protection Act, the State's groundwater resources are broken down
              into four classifications, much like the State's existing surface water clas     -
              ifications of A and B. Currently, Exeter's stratified drift aquifers, as mapp:d
              by the US Geological Survey, are classified as GB groundwater resources.       All
              other areas of the community are classified as GB groundwater resources.

              Municipalities have the option of upgrading the classification of their ground-
              water resources to either Class GAl or GAA. These classifications afford more
              protection to a community's groundwater resources, however, they do require BMP
              compliance inspections as part of the management plan.

              Regarding the second task, the Town would send notice to all PCS owners, alerting
              them that their business/use is located within a contributing area of a municipal
              water well. The notice would inform the owners of the Town's Wellhead Protection
              Program, the need to comply with the State's Best Management Practices (BMP)
              administrative rules, and would include the BMP rules as well as a groundwater
              protection educational flyer. The notice would also let the PCS owner (Exeter
              PCs owners only) know that a BMP compliance inspection will be scheduled shortly.

              Regarding the third task, the Health Officer (or other duly appointed agent)
              would conduct BMP compliance inspections for the PCSs included in the management
              plan. At a minimum, the inspections must take place on a three year cycle. New
              PCSs would need to be integrated into this cycle.

              Pros: This option would provide the Town with much more assurance of BMP
              compliance than the options listed previously. A GAl classificati.on would apply
              to Exeter as a whole, thus, necessitating BMP compliance inspections for every
              PCS in the city. This would'be considered a benefit if Town-wide groundwater
              protection is the goal. This option would also enable the Town to apply to the
              State for the Phase II and V water testing waivers.



                                                      3










            The GAI classification would allow the Town to issue cease and desist orders to
            those PCSs which are not in compliance with the State's BMP rules.    Fines could
            also be imposed for non-compliance. It should be noted that cease and desist
            orders and fines are not required to be issued in all cases of non-compliance,
            rather, it is up to the inspector to determine whether negotiation or fines would
            be more effective.


            Cons: Conducting BMP compliance inspections for every PCS in Exeter would be
            prohibitively expensive and, since most of the Town's PCSs are located outside
            of the municipal well's WHPAs, inspecting these sites would do little to protect
            the water quality of the municipal wells. Also, a GAl classification would not
            give the Town the authority to inspect the PCSs found within the WHPAs located
            outside of Exeter.


            Costs would be incurred for the inspections, legal actions resulting from the
            inspections, and maintaining the PCS inventory. Another requirement of the GAl
            classification is that every citizen of Exeter must be notified of the Town's
            Wellhead Protection Program and given groundwater          protection education
            materials.   Such a Town-wide mailing would be another expense to consider.

                                                Option #4

            1.    Reclassify the Town's groundwater resources to GAA

            2.    Notify PCS owners and land owners within the WEPAs

            3.    Conduct BMP compliance inspections

            4.    Maintain PCS inventory



            The method of implementation would be the same as outlined under option #3,
            except the Town would apply for a GAA reclassification.. The Town would also need
            to work out inter-municipal agreements with the other communities (Stratham)
            which contain WHPAs for the municipal wells, in order for the Town to inspect
            the PCSs within the WHPAs located outside of Exeter.


            Pros: The GAA classification would be applied to only those areas (both inside
            and outside Exeter) within the identified municipal water well's WHPAs.        The
            remaining land within the Town would not be included in the program, thus, a
            Town-wide PCS inspection program would not be necessary. Exeter's BMP compliance
            inspector would be given the authority to conduct inspections within the WHPAs
            located outside of Exeter, assuming the proper inter-municipal agreements could
            be reached.


            The GAA classification would also enable the Town to apply to the State for the
            Phase II and V water testing waivers. In addition, the Town would be authorized
            to issue fines and cease and desist orders to those PCSs which are not in
            compliance with the State's BMP rules. Lastly, six high risk land uses would be
            automatically prohibited from locating within the identified WHPAs (both inside
            and outside Exeter).     These six land uses are: landfills, hazardous waste
            disposal sites, outdoor salt storage, junk yards, snow dumps and septage lagoons.
            While Exeter's Aquifer Protection Ordinance does already exclude these uses from
            the aquifer areas, such designation would provide another layer of protection and
            would include a small area Skinner Springs wellhead area in Stratham.

            Cons: This option is more expensive than the first two, however, much less
            expensive than option #3. Town-wide groundwater protection would not be assured,


                                                     4











              however, the Town would be able to focus its resources on those land areas which
              actually contribute water to the municipal water wells.

              Costs would be incurred for the inspections, legal actions resulting from the
              inspections, maintaining the PCS inventory, and the time its takes to arrange the
              inter-municipal agreements. Another requirement of the GAA classification is
              that all property owners within an identified WHPA be notified about the Town's
              Wellhead Protection Program and given groundwater protection education materials.
              Such a mailing would be another expense to consider.


                                                Recommendation


              In terms of program costs versus potential benefit, clearly Option #4 would be
              the most appropriate.      This makes sense if the goal of Exeter's Wellhead
              Protection Program is the protection of municipal well water quality as opposed
              to Town-wide groundwater   protection. The GAA classification will provide the
              authority to inspect the   PCSs in the identified WHPAs (both inside and outside
              of Exeter) while avoiding the prohibitive cost of conducting Town-wide PCS
              inspections.

              While Exeter has already taken some steps to protect its aquifers, wellhead
              protection programs add an additional layer of protection and, in all likelihood,
              will save the Town of Exeter well testing costs. with this program waivers can
              be granted so to allow Exeter to test       less frequently, in exchange for BMP
              inspections. It appears that there are      a minimal number PCSs in the wellhead
              areas and, since inspections are required  on a three-year  basis, the costs should
              be minimal. It is impossible to estimate how much time an inspector would have
              to devote to situations of non-RMP compliance, however, once we firmly determine
              the number of PCSs in these areas, the costs should be more definitive.
              Additionally, the cost of training and education will be provided by the DES
              Groundwater Protection Bureau at no additional cost to the City.

              Please contact me should you need additional information.          As soon as the
              wellhead delineations are completed, I will contact you for review. If you have
              any questions or comments please contact me at your earliest convenience.



























                                                        5


POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM



INSTRUCTIONS: This form should be completed for each PCS. It should be updated as necessary each
time an inspection of the potential contamination source is performed.


PCS INFORMATION:

PCS Name:  
Address:

Town:					Tax Map:			Lot Number:


PCS OWNER INFORMATION:

Owner Name:								Phone Number:
Address:

Town: 					State:		Zip Code:



PCS CONTACT PERSON INFORMATION: (complete only if different from above)

Contact Person:  Joe O'Hati					Phone Number:
Address:      141 Portsmouth Ave.

Town:					      State:		Zip Code:



PCS Type (see list on back): motor vehicle service/repair



SIC Code (see PCS/SIC matching tables in inventory guidance document):







-1-











                                                POTENTIAL CONTAMINATION SOURCE INSPECTION FORM


                          INSTRUCTIONS: Sections one and two of this form should be completed for every inspection of a potential
                          contamination source (PCS) performed. Sections three and four should be completed for Best Management
                          Practices Compliance Inspections only.

                          Section One:

                          Date of Inspection:  6/30/95

                          Name of Potential Contamination Source (PCS):  American Brake Service    

                          Town PCS Located in: Exeter

                          Inspection Type (check one):
                          Initial Verification                       Best Management Practices Compliance

                          Name and Title of Person(s) Performing Inspection:
                                                      E. Ware, B. Caneau      

                          Name and Title of Person(s) Providing Information about the PCS:
									Joe O'Hati

                          Section Two: Questions to ask the PCS representative to determine if they are a PCS subject to BMP
                          (Env-Ws 421) because they use, handle, store, or dispose of regulated substances

                          1  What regulated substances do you use, handle, or store?  Please complete the following chart if the
                          substance is not used, please write N/A. (Suggestion Let the PCS representative fill out the chart.                                        

                                                                                  Quantity (Gal)										Quantity (Gal)
                          Antifreeze (for gasoline or coolant system)               1 gal.             Disinfectants								0

                          Automatic transmission fluid					24 qts             Road salt 									0

                          Engine & radiator flushes                              	4 gal.             Reingerants								0

                          Hydraulic fluid (including brake fluid)                   25 gal.            Fertilizers (if stored outdoors)					0

                          Motor oils/waste oils                                     300 gal.       	 Pesticides (insecticides, herbicides,
                                                                                                       rodenticides)								0
                          Gasoline jet fuel                                       	0                                                        
                         													 Photochemicals    							0                                    								
                          Diesel fuel, kerosene, #2 heating oil				500 gal.                                                                                                       Printing ink
                        													 Printing ink								0		
                          Other petroleum products (grease lubricants)			10 gal.
                                                                                                       Wood preservative (creosote)						0
                          Degreasers for engines, metal, driveways			0
                          and garages                                                                  Lye or caustic soda							0
                         
                          Banery acid (electrolyte)                               	0                  Jewelry cleaners or metal polishes					0

                          Rustproofers                                              0                  Leather cleaners								0

                          Car wash detergents, waxes, and polishes                  0                  PCBs										0

                          Asphalt & roofing tar							0			 Other chlorinated hydrocarbons		
                                                                                              		 including carbon tetrachloride					0
                          Paints, varnishes, stains, dyes                           0                      
                                                                                                       Any other products with "Poison" labels   
                          Paint & lacquer thinners, paint brush                     0                  (including chloroform, formaldehyde,
                          cleaners and floor & furniture strippers                                     hydrochloric acid, other acids)    				1 gal

                          Spot removers & cleaning fluids (dry                      2 gals.            Other products not listed which you feel
                          cleaners) or other cleaning solvents                                         may be toxic or hazardous (please list)

                          Cesspool cleaners							0



                                                                                               -2-


Type of 				Quantity				
Waste Produced			Generated/Year			Disposal Method Used
OIL/break fluid			300 gal yr.
Waste Management

anti-freeze								 	       




Note: Contact the NH Wellhead Protection Program (271-3431) with questions or concerns regarding
reported disposal practices.

Section Three: If the PCS is subject to the BMP rules, ask them the following questions to determine
compliance during a BMP compliance inspection:

Storage of Regulated Substances (refer to Env-WS 421.04)

Where are the regulated substances stored which were described in section 2? (Describe here and/or sketch
on the back of this form.)





Ask the following questions to determine compliance with BMP rule Env-Ws. 04

Yes No (N/A)

1	        	Is there an impervious surface under the regulated substances?
Env-Ws 421.04(b) If no, describe:


2.			Is the storage area(s) secured against unauthorized entry (i.e. bung locks, surveillance, etc)?
Env-Ws 421.04(c)	If yes, describe:

3.			Is the storage area(s) inspected weekly for signs of spills?
Env-Ws 421.04(d)

4.			Is there sufficient space between large containers to allow for inspections?
Env-Ws 421.04(d)	




5)			Are regulated substances which are stored outside covered?
Env-Ws 421.04(e)	If yes, describe:


6.			Are regulated substances which are stored outside > 50 feet away from a surface water body?
Env-Ws 421.04(f)

7.			Are regulated substances which are stored outside > 75 feet away from a private well?
Env-Ws 421.04(f)

8.			Are regulated substances in outdoor storage areas stored outside the protective radius of
Env-Ws 421.04(f)	public water supply wells? (Radius is usually 200 or 400 - contact 271-3431 with questions.)

9.			Do outside storage areas contatining an aggregate of > 275 gallons (5 drums) of regulated
Env-Ws 421.04(g)	substance have secondary containment (i.e. berms)?




-3-



POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM




INSTRUCTIONS: This form should be completed for each PCS. It should be updated as necessary each
time an inspection of the potential contamination source is performed.


PCS INFORMATION:

PCS Name:  
Address:   Portsmouth Ave.

Town: 				Tax Map:			Lot Number:


PCS OWNER INFORMATION:

Owner Name:							Phone Number:
Address:

Town:						State:		Zip Code:


PCS CONTACT PERSON INFORMATION: (complete only if different from above)

Contact Person: Cliff Cote, Service Manager	Phone Number:
Address:       same

Town: 					State:		Zip Code:



PCS Type (see list on back): vehicle service & repairs



SIC Code (see PCS/SIC matching tables in inventory guidance document):








-1-

		

~0






                                                 POTENTIAL CONTAMINA~0qMN SOURCE INSPEC~q1~q1~2qON FORM


                           IN~8qSTRUC~-~4qn~6qON~0qS: Sections one and two of this form should be oompl~eted for every inspection of a potential
                           contamination ~so~u~r~c~ee (PG~4qS) perfor~l~i~r~ted- Sections three and four should be completed for Best Management
                           Practices ~8qC~-~qor~4qw~qr~qw~ir~i~qm ~qk~8qq~D~e~6qd~qi~qo~i~n~s only.

                           Section One:

                           Date of Inspection:
                           Name of Potential C~-ontaminati~o~n Source ~q(~qF~ICS~q):~.                            ~q1~q6~2q&~0qk~6qA~2q@~qz~qV~2qb~,~,_

                           Town PC~6qS ~qC~o~cat~ed in:

                           Inspection Type (check o~n~e):
                           Initial Inventory Verification                                    Best Management Practices ~0qComp~qhar~qr~a~e

                           Name and Title of P~er~s~on~q(~s~q) Performing inspection-


                           Name and Title of P              n ~s Prov~qid~in ~qI~nforr~r~iation abo~u~r~qt the PCS~-
                                                                                  ~2q4~-

                           Section Two: Questions ~to ask the PCS representative ~to determine it they are a PC S su~o~j~@:~@~-~! ~1~,~-~)
                           (Env-WS 421 ~q) because they use. handle. store. or dispose of regulated substances

                           I What regulated substances do you use, handle. or store" Please complete ~1~h~r lo~i~io~_~,r~)~,-~,
                           substance is not used. please write N/A (Suggestion ~_e~i me PCS rep~resen~ia~i,~e                                        ~u- ~i

                                                                                   ~qD~ua~n~q2~p~y~-~q(~C~l~a~l~)
                           An~utre~eZe ~(~lo~( gasoline or coolant system)                    ~2q7~8qV~q-~2q9~~0q4~1~e~- D~@~s~,n~lec~ta~n~r~s
                           Au~ton,a~uc transmission fluid                                                    R~o~a~o sap ~(~na~i~n~e~)                                              ~q6~z~2qu

                           Engine & rac~i~tat~o~f ~f~lus~r~@e~s                                                     ~F~l~et~i-~i~r~iera~nts


                           Hydraulic fluid ~q(i~n~du~ding brake ~nui~d~)                                           ~Per~t~i~l~t~ze~(~s ~(g~i ~st~ore~a out~ooor~s~)
                           Motor oi~ls~rwaste o~d~is                                        ~8q6~4q0~1~2q2~2q&~8qL             ~P~es~t~i~oc~ies ~q(~i~n~S~e~c~D~qWe~S. her~i~)~-~oo~e~s
                                                                                                           ro~de~n~dc~oes~)
                           Gasoline. jet fuel                                            ~/~2qY~l~ql~l~0qy~z~qe~_
                                                                                                  -    .   P~ho~to~c~nem~ica~t~s
                           Diesel fuel. kerosene. ~92 heating o~i~l                         ~.~q1~6qy~0qo~l~"~qI~4qt
                                                                                                           Printing ink
                           Other petroleum ~pro~du~c~:~ts (grease. l~i~j~b~iri~c~an~r~s~q)
                                                                                                           Wood pre~serv~at~r~ve (creosote)
                           Degr~ea~sers for engines. met~a~J. d~r~iv~erw~ays;
                           and garages                                                                     Lye Or c~aus~D~c soda

                           ~sane~fy acid ~q(e~iec~iroty~ie~q)                                                       J~ewe~2q" c~lea~r~qws or metal ~po~l~ts~qNe~s
                           Rus~tp~r~oote~ir~s;                                                ~qt~A~qt~q)~0q&~1~1~0~0q4~_        Leather cleaners

                           Car ~qv~qra~qsh detergents. waxes. a~qn~qd po~qli     ~qs~qt~8q@                                   Pc~qa~qs

                           A~qsp~qha~qf~qt ~q& fooling t~qa~qf                                                           O~qt~qh~0qw ~qc~6qNo~qr~qi~qnated hydrocarbons
                           Paints. varnishes. stains. dyes                                                 ~qu~q-~qiclucl~qtng carbon te~qtra~qc~qr~qt~qi~qon~qde
                                                                                                           Arty o~qne~qi~qr products with 'Poison' ~qt~qa bets
                           Pa~qk~qa ~q& ~q1~q3~qc~qqu~qer ~qt~qr~2q*u~qie~qir~qs. paint brush                                           ~6q(ir~qi~qdudin~qg c~qh~qlo~q(~qol~qi~qo~qrm. t~qo~qfma~qi~qd~q-e~qi~qtry~qd~qe~q.
                           ~qc~ql~qi~2qmners. and floor ~q& fumi~qt~qu~qre st~qir~qipp~qar~qs,                                      hydroc~qhlo~q6~qc acid. other acids)

                           Spot ~qre~qirno~qve~qm ~q& ck~qb~qaning fluids (dry                                           Other produ~qc~q2~qs not listed ~qv~qA~qm~qc~qh you feel
                           d~qean~qe~2qm) of otter cleaning solvents                                              may be toxic of hazardous (please tis~qt~0q)

                           cesspool ~qdea~qne~qf~qs



                                                                                                       -2-
 

Type of 				Quantity	
Waste Produced			Generated/Year			Disposal Method Used
WASTE ANTIFREEZE			440 GAL			SAFETY KLEEN CORP 189A WILLOW ST  MA 01952
WASTE ENGINE OIL			800 gal			''	''	''   50A BRIGHAM MARLBOROUGH MA
															01752
OLD TIRES				200 TOTAL			MAINLINE TIRE CO. INC. 283 MIDDLE RD.
												ACHUSNET MA 02743

Floor drain or property - includes oil seperator inspected by water dept.

Note: Contact the NH Wellhead Protection Program (271-3431) with questions or concerns regarding
reported disposal practices.

Section Three: If the PCS is subject to the BMP rules, ask them the following questions to determine
compliance during a BMP compliance inspection:

Storage of Regulated Substances (refer to Env-WS 421.04)

Where are the regulated substances stored which were described in section 2? (Describe here and/or sketch
on the back of this form.)




Ask the following questions to determine compliance with BMP rule Env-Ws 04

Yes No (N/A)

1)			Is there an impervious surface under the regulated substances?
Env-Ws 421.04(b)	If no, describe:


2)			Is the storage area(s) secured against unauthorized entry (i.e. bung locks, surveillance, etc.)?
Env-Ws 421.04(c)	If yes, describe:


3)			Is the storage area(s) inspected weekly for signs of spills?
Env-Ws 421.04(d)	

4)			Is there sufficient space between large containers to allow for inspections?
Env-Ws 421.04(d)



5)			Are regulated substances which are stored outside covered?
Env-Ws 421.04(e)	If yes, describe:


6)			Are regulated substances which are stored outside > 50 feet away from a surface water body?
Env-Ws 421.04(f)	

7.			Are regulated substances which are stored outside > 75 feet away from a private well?
Env-Ws 421.04(f)

8.			Are regulated substances in outdoor storage areas stored outside the protective radius of
Env-Ws 421.04(f)	public water supply wells? (Radius is usually 200 or 400 - contact 271-3431 with questoins.)

9.			Do outside storage areas containing an aggregate of > 275 gallons (5 drums) of regulated
Env-Ws 421.04(g)	substance have secondary containment (i.e. berms)?



-3-



POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM




INSTRUCTIONS: This form should be completed for each PCS. It should be updated as necessary each
time an inspection of the potential contamination source is performed.


PCS INFORMATION:

PCS Name: McFarland Ford
Address:  Portsmouth Ave.

Town: Exeter				Tax Map:			Lot Number:


PCS OWNER INFORMATION:

Owner Name:									Phone Number:
Address:

Town:								State:		Zip Code:


PCS CONTACT PERSON INFORMATION: (complete only if different from above)

Contact Person: Michael            /Service Manager		Phone Number: 772-5953
Address:  same

Town:								State:		Zip Code:



PCS Type (see list on back): vehicle service & repairs



SIC Code (see PCS/SIC matching tables in inventory guidance document):








-1-



~0






                                                  POTENTIAL CONTAMINATION SOURCE INSPECTION FORM


                                                                                                                                                 i                             ti~a
                            IN~qST~4qR~qt~qiCT~qIONS: Sections one and two of this form should be completed for every inspection of a p~qoten I
                            ~cor~qoamin~a~4qmon s~o~u~r~qr-e (I~qR~4qC~4qS~q) perforn-~te~8qd. Sections ~qO~que~e and four ~s~ql~0qm~ql~qd tie completed for Best Management
                            Practices ~2qG~qm~0qpl~qian~qm In~i~qspe~ct~qion~is only.

                            S~e~c~q6~on One:

                            Date of inspection:

                            Name of potential Contamination Sou~r~ue (PCS~q):
                            Town PCS Located in- ~. ~0q0~q/~,~8qP~- A

                            Inspection Type (check one)-
                            ~qIn~qit~qL~-~qd Inventory V~er~qif~qic~a~ql~qion            ~4qz                       Best management P~r~z~ict~qic~es ~0qC~or~np~lia~n~c~e

                            Name and Title of P~e~r~x~;~on(s) P~e~rf                  ~qi ~q9 ins
                                                                   ~0q6~6q7~8q@~/ ~6q7~d~,

                            Name a~n~qd T~i to of P~or~son(~s) P ~qi~qdi I f                                            ~qIh
                                                                    ~8q7ov ~ing no                lion ~0qS ~qJ~2q@~qPCS:                                                     ~q5~-~2q1 ~2q5~2q@3

                            Section    Two ~0qOues~i~i~on~s ~to ask ~the PCS representative to determine if they are a PCS su~b~je~c~i ~io Bm~p ~r~u~i~c~'~,
                            (Env Ws     ~421 ) because they use, handle. store, or dispose of regulated substances

                            ~1   wha~i f~egu~la~te~qd substances do you use, handle. or store) Please complete ~1h~e ~lo~l~iow~in~o c~na~n If Me
                            substance is no~t used. please wr~ne N/A (Suggestion Let ~t~he PCS represen~ia~t~we ~1~,~1~1 ~O~L~)~i ~i~n~e ~C~r~l~'~j~r~" ~)                                                                I

                                                                                    ~qOu~a~n       Call                                                             O~ua~n~i~)~r~y ~(c~@~j~;~@
                            A~n~D~r~y~e~e~te (,or gasoline or o~oo~i~an~t system)                                      Disinfectants


                            A~A~J~1~0~n~%a~DC ~trar~k~sm~i~ss~ion fluid                                                  P~-oa~o san ~q(~ha~i~n~e~q)
                            ~F~i~-~ig~i~ne & radiator flushes                                                     Ret~ngera~nt~s                                             ~qJ`o      ~0q95
                            Hy~d~(au~b~c ~flu~d (including brake fluid)                           ~6q0               ~Per~b~l~ue~rs ~q(~i~t stored outdoors)
                            ~&~4~oE~or o~t~L~vwa~s~te ods                                      70~2q0-                  Pesticides ~q(~in~s~e~c~t~c~id~es. ~he~f~b~i~a~0e~s.
                            C-t~so~l~i~r~,e. ~te~t ~t~L~q~-~4                                                           ro~den~b~o~des~q)
                                                                                                            P~no~toc~hem~ica~ts
                            O~bes~e~-~4 ~K~oel. kerosene. ~r2 hea~b~ng ~o~i~l
                            other Petroleum products (grease. lubricants)                                   Printing ink
                                                                                                            Wood preservative (creosote)
                            De~grea~se~rs ~f~i~x engines. metal. driveways
                            and garages                                                                     Lye o~r ~ca~, tic soda

                            Battery acid ~q(e~t~e~qm~oty~te~q)                                                        j~e~@e~iry ~c~i~oa~ne~rs or met~a~i polishes


                            Ru~s~tprooters                                                                    L~e~a~d~ier cleaners


                            Car wash detergents. waxes. and polishes                                        PcB~qs

                            Aspha~qf~qt & roofing tat                                                           Other chlorinated hydrocarbons
                            Paints. varnishes. stains. dyes                                                 including carbon t~qe~qt~qrach~ql~2q@
                                                                                                            Any other products with -Poison* ta bets
                            Paint & ~qt~qaoquer ~qV~q*~qv~qv~qN~qs. paint brush                                             (i~qn~qd~qu~qd~qing chloroform, I~qf~qo~qrma~qld~q6e~qhy~qd~qe.
                            cleaners. and floor ~q4~q& ~ql~qum~qi~qt~qtu~qr~qe s~qir~6qk~qopers                                      hydrochloric acid. other acids)

                            Spot removers & cleaning fluids (dry                                            0~q0~4qw products not t~qi~qc~qn~qad which you led
                            cleaners~4q) of Other Cleaning solvents                                            may be toxic o~qir ~qh~8qua~qir~qd~qou~qs (please list)

                            cesspool cleaners



                                                                                                                                          ~q-~8q2
                                                                                                        2 -                               Z~q'
                                                       ~28qI~6qt~04qu ~92qZ ~20qf~6qt~q, ~92qZ~q,
 

~0

            ~qMiat type of wastes do you produce?

                 Type of            Quantity
              Waste Produced      Gener~te~qd~Year          D     ~qM~~qM~d Used
                                                  ~qC~ql~qm~-~) ~q=~~~qe~qf ~       ~C
                                                 ~qf~ql~qi~c~qy~c~qi~(~8qA ~4q0~,~-~) ~-~8qS~'~,~q7~qT
                                                  AIL ~6q0~1~r~qA~1~C~1~;~9 ~4qr~q@~q@~1~1~q2
                  ed ~6qAZ~0qA~q!~4qM~qr

          Note: Contact the NH Wellhead protection Program (271~-3431) with qu~e~s~qf~i~on~s or concerns regarding
          repoct~ed ~c~q9~spo~e~qal pr~actiC~x~-~1~8~.
          Section Three: ~qIf the PC~6qS is subject to the ~4qB~0qmP rules. ask them the following questions to det~e~n~T~q@n~e
          compliance during a B~8qMP compliance i~nspect~qk~w~r

                          Storage of Regulated Substances (refer to E~r~Tv-W~qS 421,04)

          Where are the regulated substances stored which were described in section 2~*~) (Describe here arid/or sketch
          on the back of this form.)





          Ask the following questions to determine compliance with BMP rule Env~-W~S~.04~@

           Yes No (N~qIA)

                     Is there an im~qp~erv~qiou~s surface under the regulated substances?
          E~n~v~-W~9421.Cw1~q(b) ~qIf no, describe:



          ~20q-
          2~q)~q-        Is the storage ~are~a(~s) secured against una~qwhor~qized entry (i~.~e~ bung ~qlo~ck~g~. surveillance. etc
          ~4;52qr~.-~-W~& 421.04(~c) ~qIf yes. d~e~scr~qd~>e:


          ~-3~q)~q- -  ~q-  Is the ~st~on~a~qge ar~ea(~s) inspected wee~ql~qdy for signs of ~8q*~qIls?
          E~n~v~-W2 421 ~-~8q"~d)

          4) - - -   Is there sufficient space between large containers to allow for inspections?
          ~*~qF~-~n~v-W~e ~421 ~qZ~4~q(~qd)



                     Are regulated substances which are s~qtor~ed ou~ql~sid~e oovered?
          ~qE~iw~-W3421.04~q(~0~q) If yes. de~3~cribe:


          ~'6) - - -  Are regulated substances which are ~tst~ored outside ~> 50 feet away I ~r~om a surf ace water body?
          ~0qG~qi~qy~q-W~qs 421.04 M

          ~q-~6q1) - - -  Are regulated substances which are stored outside > 75 feet away from a private well?
          ~0qG~qn~q%~q,W~qa 421 ~2qA4


                     Are regulated substances in outdoor storage areas stored outside the protective r-~qa~32q&us ~qof
          E~qnv~q-W~qz 421.04 (~0q0 public water supply wel~2ql~qs?~2q(Rad~6qiu~qs is usually 2~2q0~24qY or 4W - contact 271 ~q-~08q343~0q1 with questions.)

                     Do outside storage areas cor~q-~0qnain~8qi~qn~4qg an aggregate of > 275 gallons (5 drums) of regulated
          ~4qE~qnv-W~qg~qt 4~q21~q.~qn4~2ql~2q[~4qg~6q) ~qsub~qs~04qu~qnce have secondary containment (i-e~q. berms)?

                                             A-3-
 

~0


          ~~~ J~~ ~~ I ~~~ ~~~~~~ ~~~ ~~~~     ~~"                                  to 002











                     POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM



             INSTRUCTIONS: This foff~n should be completed for each P~0qCS~. It should be updated as necessary each
             time an in~sp~e~c~t~q3on of the potential ~o~ontar~r~qdnation ~a~qmrce is performed.

             PC~qS INFORMATION:              ~8qA~4qw~A~qe,
                                       ~qf~2qt~,~:~c~-~-
                                         ~, ~q1         4
             PC~qS Name:                              7           ~6qk~-~1~q/~qz,
             Address:


             Town:                        Tax Map:              Lot Number.



             PC~8qS OWNER INF~4qQ~qR~8qMAT~qI~qC)N:
             Ov~qm~er Name: ~6qT    4 ~q1~qA~8qP~2q0                        Phone Number.
             A~qd~qdr~ee~ss


             Town:                               State:           ~qZ~qi~P~6qC~q*~qd~e~.


             PC$ C~2qQNTA~8qCT PERSON INFORMATION- (complete only ~qi~qt different from above)

             Contact P~er~5on:    ~8q6~-~4qk~A~q- ~2qa~q;~-~s ~qr~q&~2qW~q-~,~-~q-           Phone Number
             Address:


             Town:                                State:          Zip Code:



                                                     ~e
             PCS Type (see ~6q6~A on bark): ~qL~8q9~2qV~q;~,~0qL ~qt~qi~q@~4q@~2qO~4qz~z~2qf~. 9  ~4q5~j~0qz~8qo


             SIC Code (see PCS~qIS~qIC matching tables in inventory guidance document):
 

~0






                                                   POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                             INSTRUCTIONS: Sections one and two, o~qf~th~qis form should be completed for eve~ty inspection of a potential
                             con~qtarr~tir~t~qa~ql~qion ~so~L~u~ice ~q(~2qP~6qC~4qS~q) perf~qom-~ted. ~4qS~ec~:~qf~qion~s three and four should be completed for Beat Management
                             P~r~6q=ice~S ~2qComp~qr~qo~f~ic~e ~qh~i~specti~qo~qm only.

                             Se~c~Ition One.-

                             Date of Inspection:
                             Name of potential Contamination Source (FIGS):                                              ~0q6~Z~q4 ~4q0~1~1~q1~qi~q)~4qf~4qf~-

                             Town ~8qPCS Located in:


                             Inspection Type (check one),
                             Initial lave" V~e~r~qif~qi~r~-~2qm~qion                ~qV~8q/~'                      Best management Practices ~0qC~omp~qi~qta~r~icc~e

                             Name and Title of Pe~r~so~n(s~ql Performing Inspection:


                             Name and ~4qTt~qlo.~qQf P~qq~r~q@~@on(~s) Providing I~nfo~rTnat~qion abo~c~qA the PCS-
                                         ~qi~ql~4qb~i~q(~2qA~qi ~q/~4qV-~0qp~0qp ~qv~2qx~6qi~0qs~4qc~k~q- - ~8qc~2qn~i~-~v~0qw-~qi ~- ~q@~qi~2qe~j~-~6qU~-~, ~2qk~, ~8qF~,~q?~,

                             Section Two Questions ~to ask the PCS represen~ta~i~rve lo determine if ~ihey are a PCS su~iD~ie~c~i ~i~o ~qq~qv~f' ~r~ui~t~2~,~,
                             (Env-Ws 421~q) t~>ecause they use. handle. store. or dispose of re~qgul~a~i~e~qo su~osia~nces

                             I What regulated substances do you use. handle. or s~iore) Please ~com~D~le~ie ~i~n~e ~lo~i~io~-~n~qg ~@~n~qx~7
                             substance is no~t used. please write N/A~ (Suggestion Lei the PCS ~rep~tesen~ia~i-~e ~1~.~11 ~0~'~J~i ~qM~u ~C:~)~j:~l



                             A~.nt~i~r~re~e~ze (to, ~ga~-~%o~l~l~r~,~*~e ~o~( coolant system)


                             ~!~A~:utorn~a~nc ~tra~n~s~m~ts~-s~ion fluid                                                  Road s~an ~(~r~L~w~n~e~)
                             Engine ~& radiator nus~t~v~e~e~s                                                       ~R~etr~i~gefa~n~t~s  ~0qa~2qv~q;~A~n

                             Hydraulic fluid (including brake fluid)
                                                                                                              ~F~-e~n~i~t~ze~irs (it ~s~l~o~te~o oyt~oo~~or~s~)
                             Motor oi~ls~q@a~s~ie o~i~ts                                         2~q;-                 Pe~s~b~o~o~es. ~q(in~s~e~c~i~i~qw~e~m~s he~rt~i~i~c:~i~ae~s~
                             Gasoline. jet fuel                                          Oft                  ro~o~e~n~b~o~oe~s~)
                             Diesel fuel. kerosene, ~sr2 heading o~a                                            ~P~notoc~r~@em~t~ca~ts                                           ~8qo  I~;~6q@
                             Other petroleum products (grease. lubricants)                                    Printing ink                                              ~2qW~qN~4qM
                                                                                                              wood pre~s~erv~at~r~@e (creosote)
                             De~g~r~eas~er~s; for engines. metal. driveways
                             and garages                                                                      Lye or - ~t~i~c soda

                             Battery acid (e~tec~tr~o~lyte~q)                                                       Jewelry dea~r~o~ws or ~me~ta~i Polishes

                             Rus~qtpr~qoo~qt~qers                                                                     Leather cleaners

                             Ca~qr wash detergents. waxes. and polishes                                         P~qC~qB~qS
                             A~qsp~qha~qf~qt & roofing ~8qm~qr                                               A-            Other chlorinated hydrocarbons
                             Paints. varnishes. stains. dyes                                   A-             ~qv~qic~qlu~qoin~qg carbon te~qua~qC~qh~ql~qo~qr~qb~qd~qG
                                                                                                              Arty other prod~qu~qc~qm with -Poison- Labels
                             Paint & Lacquer ~2qf~2qt~qv~qt~qoer~qs. paint brush                                            ~2q(~qax~qIudi~qng chloroform. lormak~qse~qhy~qd~qe.
                             ~qc~qL~qea~qner~qs. and A" ~q& I~qturn~qirtur~qe s~qwipp~qers                                          hydrochloric acid. o~qa~q-~q.e~q( acids)

                             Spot re~qrnove~qir~qs ~q& cleaning fluids (dry                                           Other products not listed wt~qv~qch you feel
                             dea~qner~qs) of o~qV~2qw ~qd~qea~qr~qi~qk~00qV solvents                                                 ~qr~qr~qiay be to ~qK~qi~qc~q- of hazardous (please ~6qW~8q)

                             Cesspool c~qlear~qi~qers                                                                                                             ~6qV



                                                                                                          -2-
 

~0

                    2. What type of w~~t~~ do you produce?

                               Type of                           Quantity
                          Waste Produced                     G~ner~ted~fYear                             ~qD~qL~qVo~a~l Method Used
                                 ~q+~~i~~qo~;                                   ~. ~         ~-~q" loci
                              ~qJ~4qA~q@~6q@ CA                                                                         ~8qn~qi
                                                                                                                 ~L~A

                       ~qI~qJ~4q&
                                                                      ~qq~6qt~6qd~6qL~qC~qA~6qA~-~-~0qt       ~qt,

                    Note: Contact the NH Wellhead Protection Program (271~,3431) with questions or c~on~c~orns regarding
                    reported disposal practices-
                    Section Three: ~qI~qf the PC~6qS is subject to the ~4qBMP rules, ask them the following questions to d~e~tem~vn~e
                    compliance during a ~4qBMP compliance inspe~ctior~r

                                               Storage of Regulated Substances (r~ef~or to Env-WS 421.04)

                    More are the regulated substances ~i~stor~ed which were d~e~scr~8qb~ed in section 2~1 (Describe hem and/or sketch
                    on the back of ~1hi~s fon-~n~-~q)




                    Ask the following questions to determine ~oomp~qli~ance with BMP rule E~nv-W~s.04~@

                     Yes No (~8qWA)

                    ~28q'
                    ~q1) ~q- ~q- ~q-          Is there an impervious surface under the r~e~qgu~qla~ied ~8ub~s~i~sn~c~e~9~9
                    ~8;56qv~-W~S 421.04~q@b)  If no, describe:



                    2~q)~q-               Is the storage are~a(~s) secured against unauthorized entry (i.e. bung locks. surveillance. etc
                    E~n~v-W~& ~42~io~4~q(c~q)   If y~a~s~. de~s~cri~qh~o~e:


                    ~*~q3)               Is the storage are~a(~s) inspected weekly for signs of spills?
                    En~v-W~3 421 .04~q(d)                                                                     I

                    4) - - -          18 there sufficient space between large containers to allow for inspections?
                    En~v~-W~rA~21~1~qDA~q(d)




                                      Are regulated sulbstances which are~s~qtored outside covered?
                    Efw~-W3~4~21.04~q(~0~q)   If yes, d~e~s~c~@~r~qibe:


                    ~'6)               Are regulated substances which are ~5~q1~o~red outside ~> 50 feet away from a surface water body?
                    En~qv~q-W~qg 4~q2 ~qi~qo~q4 M

                    ~q*~8q7) - - -         Are regulated substances which are stored outside > 75 feel away from a private well?
                    ~qE~qA~q-~qW~q-W~qa 42 1~q.~q04L ~2q(~q1)

                                      Are regulated substances in outdoor storage areas stored o~qL~qns~0qid~qg the protective r~qad~2q[i~qu~qs of
                    E~qny~q-W~qx 421.04 (~0q0  public water supply we(~2qts?~2q(~16qRadiu~qs is usually 2~6q0~6q0~qr or 4~24qW - contact 271~q-3431 with questions.)

                                      Do outside storage areas co~00qmai~qning an aggregate of > 275 ga~2qf~2qlo~qn~qs (~4q5 drums) of regulated
                    ~4qE~q1~q'~qV~q-~00qW~q*  42~qi~2qz~q4~2q(g~6q) substance have secondary containment ~4q(~qLe~q. berms)?



                                                                                   -3-
 

~0








                                                       Attachment 6
                                                        (Page 1 of 7)


                   POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM (DRAFT)




             INSTRUCTIONS: This form should be completed to, each PCS, ~q1~q1 should be updated as necessary each
             time an inspection of the potential oontarnina~qtion source is performed.


             P~2qQS INFORMATION:

             PCS Narne:
             Address:        ~q1~2qq~q1     ~8qr~8q4~qf~,~q@~q@~8qO~q"~6q6~,~qL~2qt~0qL-

             Town:                                    Tax Map:                       Lot Number


             P~2qQS OWNER INFORMATION:

             Owner Name:          ~q1~q"~I~'~l~e~4                                       PhoneN~umbe~(
             Address:


             Town:                                             State:                   Zip Coc~ie


             P~2qQS CONTACT PERSON INFORMATION: (complete only if different from above)
             Contact Person-..                       ~2q4~q2~1~1~1~k~_~%~q@                   Phone Number
             Address:


             Town:                                             State:                   Zip Code:



             PCS Type (see list on back):  ~f~4qf~4qt~0q#~8q6~6qV



             SIC Code (see PCS/SIC matching tables in inventory guidance document):
 









                                                          Attachment 6
                                                          (Page 2 of 7)




                                           Potential Contamination Sources
                              Subject to Compliance Inspections with Env-WS 421


                Vehicle service and repair shops - including but not limited to: automobile, truck, and equipment service or
                repair shops. autobody shops: and aircraft fueling, deicing. and maintenance areas.

                General service and repair shops - including but not limited to: furniture stripping, painting. and refinishing.-
                photographic processing: printing: applian'ce and small engine repair. boat repair, service, and refinishing-
                refrigeration. heating, ventilating and air conditioning shops.

                Metalworking shops - including but not lirnrled to: machine shops-. metal plating. heat treating, smehing and
                jewelry making shops.

                Manufacturing facilfties - including but not limned to: electronics and chemical manufacturing. processing.
                and reclamation: paper. leather, plastic. fiberglass, rubber. silicon and glass making. pharmaceutical produc.
                tion.- pesticide manufacture.- and chemical preservation of wood and wood products.

                Waste and scrap processing and storage - including but not limited lo@ junkyards, scrap yards. and auto
                salvage yards: wastewater treatment plants. dumps, landfills, transfer stations and other solid waste lacilirlies'.
                and wastewater or septage lagoons.

                Laboratories and professional offices - Including but not limited to: medical. denial. and veterinary offices.
                and research and analytical laboratories.

                Salt storage and use - for winter road and parking lot maintenance.

                Cleaning services - including but not limited to: dry cleaners, laundromats: beauty salons-. and car washes.

                Food processing plants - including but not limited to: meat packing and slaughterhouses-, daides-. and
                processed food manufacture.

                Fueling and maintenance of excavation and earthmoving equipment

                Concrete, asphalt and tar manufacture

                Hazardous waste facilities - regulated under the Resource Conservation and Recovery Act, as imple-
                mented by RSA 147-A.1 11.


~0


                                                                                          Attachment 6
                                                                                           (Page 3 of 7)
                                     POTENTIAL CONTAMINATION SOURCE INSPECTION FORM (DRAFT)

                      INSTRUCTIONS: Sections one and two of this form should be completed for every inspection of a potential
                      contamination source (PCS~q) performed. Sections three and four should be completed (or Best Management
                      Practices Compliance Inspections only.

                      Section One:
                      Date of Inspection: & 13~0q0
                      Name of Potential Contamination Source (PCS~q):

                      Town PCS Located in:

                      Inspection Type (check one):
                      initial inventory Verification                                    Best Management Practices Compliance

                      Name a~nd Title of Person~q(s) Periorming Inspection:
                                                                ~2q6~7                      /~*
                      Name and T                ~qP             ~qP              I formation a~qb~o~u~6qm~qt PC
                                       I~qt~qle of erso             ~rov ~t g n
                                                                I        (I ~C~q4                                                AD,


                      Section Two: Questions to ask the PCS representative to determine if they are a PCS sub~qlec~i ~to BIVIP rules
                      (Env-Ws 421) because they use. handle, store. or dispose of regulated substances.
                      1. What regulated substances do you use. handle, or store? Please complete the following cha~r~ql ~If ~the
                      substance is not used. please write N/A~ (Suggestion: Let the PCS representative fill ou~qt the chart.)

                                                                               ~qo~u             ~1)                                                             Quantity ~(G~a I)
                      Antifreeze (fo~r gasoline or coolant system)                  ~6q@~4qr~8ql    ~1~I~q(~O~6qW        Disinfectants

                      Automatic transmis~s~@ion fluid                                                    Road sa~tt (ha~j~i~t~e~q)

                      Er~vg~q@ne & radiator flushes                                                       ~qR~e~f~f~ig~qwan~ts

                      Hydraulic fluid (including brake fluid)                                          Fertilizers (~i~t stored outdoors~q)
                    ~                                                          ~2qY~q2 ~@~q@~- A ~6q@
                      ~qWto~r oi~L~qvwaste oils                                                              Pesticides (insecticides. herbicides.
                      Gasoline. jet ~qW                                                                  roden~qt~6des~q)
                                                2 heating ~o~il                                          Pho~l~o~c~hern~ica~is
                      ~D~k~i~rse~l fuel. kefo       ~qi~v~qi~qi ~4q@ha
                                        ~s~o~n~0q@~6qf!
                                                       ~2q" o~i~l                                           Pr~i~n~qtr~ig ink
                      Other petroleum products (grease. lubricants)
                      Degr~e~asers for engines. metal, driveways                                         Wood preservative (creosote)
                      and garages                                                                      Lye or caustic soda

                      Battery add ~q(e~lectrotyte~q)                                                        Jewelry ~ck~qaners or metal po~ltshes

                      Rustproo~t~er~s                                                                     Leather ~cl~e~a~i~ners

                      Car ~%~2sh detergents. waxes, am Polishes                                          PCBs

                      Asphalt ~q& roofing tar                                                            Other chlorinated hydrocarbons
                                                                                                       including carbon tetrachloride
                      Paints. varnishes. stains. dyes
                                                                                                       Any other products with 'Poison' tabe~qts
                      Paint & ~4qL~qw~4qqu~qer ~qith~0qInners. paint brush                                            ~8q(including chloroform, for~qr~qi~ql~qiak~qiehy~qde.
                      ~qcl~qe~qan~qi~qer~qs~q, a~qnd floor & furn~qi~4qWr~qo strippers                                        hydrochloric acid. other acids)

                      spot removers ~q& cleaning fluids (dry                                             Other products not listed which yo~qu I"
                      cleaners) or other cleaning solvents                                             ~8qmay be t~qo~qj~qd~qc or hazardous (please first)

                      Cesspool cleaners
                                          ~qC



                                                                                                   -2-
 





                                                                               A"achment 6
                       2. What type of wastes do you produce?                   (Page 4 of 7)

                                    Type  of                        Quantity
                              W te Produced              C54       enellied/Year                             DI 0 alAethod Used







                       Note: Contact the NH Wellhead Protection Program (271-1168) with questions or concerns regarding
                       reponed disposal practices.


                       Section Three: If the PCS is subject to the BMP rules, ask them the following questions to determine
                       compliance during a BMP compliance inspection:

                                                  Storage of Regulated Substances (refer to Env-WS 421.04)

                       Where are the regulated substances stored which.were descnbed in seciion 2? (Describe here and/or sketch
                       on the back of this form.)





                       Ask the following questions to determine compliance with BMP rule Env-Ws.04:

                       @Yes No (N/A)

                       .1) - - -         Is there an impervious surface under the regulated substances?
                       Env-Ws 421-04(b)  It no, describe-


                       -2) - - -         Is the storage area(s) secured against unauthorized entry (i.e. bung locks, surveillance, etc.)?
                       Env-Ws 421.o4(c)  If yes. describe:


                       -3)               Is the storage area(s) inspected weekly for signs of spills?
                       Env-Ws 421.04(d)

                       -4)_ _ _          Is there sufficient space between large containers to allow for inspections?
                       Ervv-Ws 421.04(d)


                       *5) . . .         Are regulated substances which are stored outside covered?
                       Env-Ws 421.04(e)  If yes, describe:


                       *6) . . .         Are regulated substances which are stored outside > 50 feet away from a surface water body?
                       Ervv-Ws 421.04 (Q


                       -7) - - - Do outside storage areas containing an aggregate of > 275 gallons (5 drums) of regulated
                       Env-Ws 421.04(g)  substance have secondary containment (i.e. berms)?


                                                                                      L
                                                                                      -3-


~0










                             POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM



                  INSTRUCTIONS: ~qI'h~qi~s form should be completed for each P~0qG~qS. It should be updated as ~n~e~o~e~s~sary each
                  time an ~qk~i~sp~ec~t~qion of the potential ~cont~arr~qdn~a~qt~qio~'n source is performed.


                  PC~qS INFORMATION:
                  PCS Name.-     ~l~2qe~4qk~6qe~-       ~8qk~,~.~q>~q,
                  Address-                              4~,~. ~2qf~0qf,

                  Town:                                   Tax ~qk~qkap:                     Lot Numbe~f-~.



                  ~qPC~8qS OWNER INF~0qQR~8qM~8qA~qT~qION:


                  Owner Name:                                                      P~qh~o~r~qw Number.
                  Addre~3s:
                  Town:                                            State:                  ~qZ~-~1 ~P ~~6q6~q@~q5 ~q-~0


                  PC~qS CONTACT PERSON INFORMATION: (~co~qmp~qI~c~qte only d dift~ere~n~t from a~qbo~ye)

                  Contact Per~5on:                                                   Phone Number
                  Address:


                  Town:                                            Slate:                  Zip Code:



                  PCS Type (see fist on bark):
                                                                                     ~"~q7


                  SIC Code (see PC~2qS~qI~qS~qIC matching tables in inventory guidance docurr~-~te~e~n~t~q):
 

~0






                                                    POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                             IN~qSTR~4qUC~-1~q7I~8qON~6qS: Sections ~o~ne and two of this form should be oorr~ipl~et~ed for every inspection of a potential
                             c~o~r~qd~amin~ad~qion source (PC~0qS) per~qfom-~ted- Sections three and four should be o~omp~qlet~ed for Best Management
                             Practices G~o~qr~4qw~qr~k~-~t~inc~e ~qU~r~specti~qon~s only.

                             Se~cI~qti~qon One:
                             Date of ~qIn~spe~c~4qWr~x~-                          ~2qY, 5
                             Name of Potential Contamination So~qur~q@ (PC~6qS~q):~~- ~0q6~q1~q1~,~qe,                                                     ~8qa~4qa~8q@~-~qI~qz~z

                             Town PCS Located in:

                             Inspection Type (check ~(~x~qw~q)~-~.
                             Initial Inventory V~er~qi~ql'ic~qa~qt~ion              ~qV                        Best Management Practices Compliance

                             Name ar ~4qT~,              f ~4qP
                                        ~,~qj~qJ dl~e o er~so~n(s) Pe~r~ql                           In~s~2qp


                             Name and ~"r~dl~e of P~or~s~on(~s~q) Providing ~qlnfo~r~r~n~0q&~n about the PCS~-
                                                                        ~ ~8q6~,~6qy~2q@ ~,                                    ~q2~0qd

                             Section Two Oues~i~t~ions ~to ask ~the PCS representative ~to determine it they are a PCS su~qb~je~c~i to BMP ~a~ji~e~,~
                             ~q(Env-WS 421 ~q) because they use. handle. store. or dispose o~i regulated substances

                             1 What regulated subs~ianceS do you use. handle. or store" Please ~co~qm~ol~e~ie i~n~e lo~llow-~0 chain It ~l~h~f~@
                             substance is not used. please wrrie N/A (Suggestion Lei ~i~ne PCS rep~r~esen~ia~i~--~-~@ ~1~.11 ~L~)~,~ji ~i~n~e ~c~~*~)ar~'~, ~)                                                                     I

                                                                                        ~qO~u an           I                                                                Ou~an~~)r~y ~i~C~@~o~i
                             ~A~n~t~i~f're~eze (~lo~(~ga~s~o~l~i~ne or coolant system)                                         D~i~s-~l~ec~ian~t~s


                             Auto~m~L~at~ic ~t~iran~s~qm~m~sion f~1~w~o                                                        Road ~s~-~a~n ~(~r~ia~j~it~e~)

                                                                                                   A
                             'Engine & radiator nu~s~hes.                                                          Re t~n~9e~f ants

                             Hyd~(au~t~ic ~f~%u~i~d ~q(including brake nu~i~d~).                                             Fertilizers (if s~to~te~o outdoors~)
                                                                                               A

                             Motor oi~l~s~twa~s~te oils                                              I/
                                                                                                                 Pe~s~t~i~o~des (ir~l~S~eC~D~C~Oes. he~r~t~-~o~o~es
                                                                                                                 ro~dent~i~o~oes~)
                             Gasoline. jet fuel
                                                                                                                 Ph~otoc~r~@emica~ts
                             Diesel tue~l. kerosene. ~92 hea~ung od                                                 Printing ink                                           ~8qA~qj~6ql~qi~8q4
                             Other petroleum products (grease. Lubricants~q)
                                                                                                                 Wood preservative (creosote)
                             De~grea~sers; Ilo( engines. metal. driveways
                             and garages                                                                         Lye or Caustic soda


                             Ba~tt~e~r~ry acid (electrolyte)                                                         ~J~e~rwe~t~ry ~c~i~ea~ne~f~s or ~r~r~beEa~j po~l~t~s~r~@~e~es.
                             Rust~p~i~r~oot~ers,                                                  A                   La~oe, cleaners

                             Car wash detergents. waxes. and p~qo~qltshes                                            Pc~qB~qs

                             Asphalt & roofing ~2qM~qr                                                                Other chlorinated hydrocarbons
                             Paints. varnishes, stains. dyes                                                     including carton te~quac~qh~qion~qde
                                                                                                                 Any other products with -Poison- Labels
                             Pai~0qm & ~qL~qt~qcque~qr t~qh~qEn~qi~q-~qte~qr~qs~q, paint brush                                              ~8q(inc~ql~qu~qcling chloroform~q. ~qf~qor~qr~qna~ql~qd~qIe~04q".
                             ~qc~qWaners~q. and floor ~qL turnitur~qe strippers                                            hydrochloric acid. o~qV~8qw acids)
                                                                        ~80qf ~0qe~ql~qt ~qc~6q4~qi ~8q1~qc~q, ~8q/~q,~qO~q-~q-~qr ~48qQ~q'~qi ~qL~q,
                             Spot removers ~q& cleaning 1~q1u~qids (dry                                                Other products riot lis~ql~qed which you I"
                             dean~qe~2qm) or o~qth~qe~qir cleaning solvents                                                 ~qm~qay be to& or hazardous (please fis~0qo
                                                                                                                  ~28q5~0q0~44qL~qO~0qT~q1~4q0~12q" ~4qA6~q,~q@~0q5~q-~q^~8q4~q,~qz~q- ~qo~qt~6qj
                             Cesspoo~qll ~qd~qeane~qcs                                               N
 

~0

           2- What type of w~~~~~ do you p~~~d~~~~?

                  Type of            ~qOu~nt~ity
               Waste Produced      ~qG~ener~tedfYear          D~I~posa~l ~J~Oetho~d Used

                                                         A
                                        ~P
                                   ~8q3~6qz~4qz


           Note: Contact the NH Wellhead Pr~qote~o~qf~qion Program (271-~q3431) with questions or concerns regarding
           reported ~2qd~qmpo~o~sa~ql practices~-
           Section Three: If the PC~4qS~' is subject to the BMP rules, ask them the following questions to d~et~en~-~r~qin~e
           ~c~ompl~qk~qm~ce during a ~0qB~2qMP compliance ir~tspectio~n:

                           Storage of Regulated Substances (refer to ~qEr~Tv~-WS 421-04)

           Whom are the regulated substances stored which were d~e~s~c~r~4qbed in section 2? (Describe here and/or sketch
           on the back of this form.)




           Ask ~qthe ~qlo~ql~qlo~0qO~ng questions ~qto determine compliance with BMP rule Env-W~s.~qG4~@

            Yes No (~2qWA)

           I)- ~q- ~q-    1~9 there an impervious surface under the r~egu~ql~a~i~ed ~sub~s~t~anc~es~9
           E~n~v-W~,~3 421.0~4(b~q) ~qIi no, describe:



           ~24q-
           2~q)~q-        Is the storage are~a(s) secured against unau~qiho~qHz~ed entry (i.e. bung ~qIo~ck~8~. ~8urv~e~ill~a~nc~e. etc ~q)~2
           ~8;56qr~,~-W~a ~421.04(c) If yes. describe:


                      Is the storage ar~ea(~s) inspected we~e~ql~qdy for signs of spills?
           E~nv~-W~z421~-~8q"~d)

           4) . . .   Is there sufficient space between large container-, to allow for inspections?
           ~*En~v-W~r, ~421 ~DA~q(d)



                      Are regulated substances which are stored outside o~overed~q?
           ~4qGW-W3 4~0q21~.04~q(~0~q) If yes, d~e~qwri~qb~e:


           ~'6) - - -  Are regulated ~qsub~e~qtanc~qe~s which are ~8~q1ored outside > 50 feet away from a surface water body?
           E~qn~qv~q-W~qs 421.04 ~8q(~0qQ

           ~q*~6q7) - - -  Are regulated substances which are stored outside > 75 feet away from a private well?
           ~6qG~qv~q.~q,~q-Wa 421~8q44 ~4q(~0qq

           ~q'8) - - -  Are regulated substances in outdoor storage areas s~0q1o~qr~q9d outside the protective radius of
           En~qv~q-w~qz 42 ~qi.o~q4 ~6q(~6qq public water supply we~6qf~6qts?~6q(~12qRadiu~qs is usually 2~24qW or 4~24qW - contact 271 -~4q1431 with que~0qat~6qio~qn~qs~q.)
           ~q*~6q9~6q) -- -   Do outside ~qst~8qo~0qmge areas containing an aggregate of > 275 ga~6qf~6ql~qo~qns (5 drums) of regulated
           E~qn-w~qa 42~q, ~q-~4qw~28qu substance h~qav~qo secondary containment (i.e. berms)?


                                               -3-
 

~0


                                                                                                             ~~j 00~










                           POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM



                 INSTRUCTIONS: ~qI'h~qis form should be completed for each ~qP~4qG~qS. It -h~ould be updated as ne~oe~ssary each
                 time an ~qk~i~sp~ec~t~qion of the potential o~onl~a~r~r~qin~ati~o~'n source is performed.


                 PC~qS INFORMATION

                 ~qP~8qC~qS~4qN~ame~:
                 Addr~e~6~s:


                 Town:                                  Tax Map:                     Lot Number.



                 P~2qC~6qS OWNER INFORMATION:


                 Owner Name:                                                    Phone Number.
                 A~qdd~r~e~3s:


                 Town:                                          State:
                                                                                        Zip G~od~e.


                 ~0qP~2qQ~~qS CONTACT PERSON INFORMATION- (complete only ~qd different from above)
                 ~6qc~o~8q@ Person~:                 ~qJ ~2qb~0qX~q14~-~8q2                            Phone Number,
                 Address-


                 Town:                                          State:                  Zip C~q*d~e:



                 PC~2qS Type (see fist on back):



                 SIC Code (see PC~4qS~qI~qS~qIC matching tables in inventory guidance document):
 

~0






                                                        POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                               INSTRUCTIONS: S~ec~ql~qi~qon~s, one and two of this form should be o~o~0qW~ql~at~ed for ~eve~rY ~l~n~S~qf~>~6~c~q1~qion of a po~qt~en~itial
                               Contamination source ~q(~0qP~4qG~4qS~q) perfom~ied~. Sections three and four should be completed for Best Management
                               Practices Gornpl~qianc~e Inspections only.

                               Se~c~qf~qion One:

                               Date of ~ql~r~6qq~3ect~0q*n:

                               Name of Potential Contamination Source (PC~0qS~q):~

                               Town ~4qPCS Located in:

                               Inspection Type (check one)-
                               Initial Inventory V~e~r~qif~qic~8qM~qi~o~n ~q@~q-~0qz                                         Best Management Practices ~6qC~omp~ql~-~La~r~v~oe
                               Name a~q@~8q$Ti~qd~q@~q1~8q7 of ~qP~e~qM~o~n                        e~rfo~rmin~qg Inspection:
                               Name and ~'~qr~qale of P~G~r~&on(~&) Prov~q@~qding Infon~nat~qion abo~4qo the PCS~-


                               Section Two ~2qOues~i~sons ~to ask the PCS represen~ta~i~rve ~to determine ~d ~i~ney are a PCS sub~je~c~i ~to B~qM~P r~j-~j~l~t:~,~,
                               (Env-Ws 421) because they use, handle. store, or dispose of ~F~eg~u~l~a~l~e~d su~b~s~l~a~n~ce~s
                               1    What regulated substances do you use. handle. or store) Please c~om~c~8qf~8qt~le ~i~t~)~e ~t~4qv~iowing c~r~i~an 11 ~i~r-
                               substance is not used, please wrfie N/A~(Suggestion Lei ~I~ne PCS r~e~p~res~en~i~a~i-~t~@ ~i~m ou~i ~i~ne cn~an ~i


                                                                                              ~qOua~n~t)           I
                               ~An~t~)~rTeeZe (tot ~0a~s~o~b~ne o~t coolant sys~tern)                                                ~D~i~s~-~i-~ifec~ia~n~c~,                                                       a

                               Autor~na~tic transmission flu~-~o                                                              Road ~sa~n ~(~na~i~n~e~)
                                                                                                                          Ret~n~gef an,                                                       ~Z~6q5~,
                               Engine ~S fad~ta~to~i flushes
                               Hydraulic fluid ~(i~n~d~udin~g ~txa~)~@e fluid~) ~2q/~0qa~0qu~6qe~-                                              ~F~-ert~)fi~zef s (if ~s to~r~e~a out~ac~or~s I

                               Motor o~ils~twas~te ods                                                                       Pesti~qw~es (~ir~s~e~c~D~qwe~-~s her~w~a~d~es
                                                                                                                          ro~d~@e~ent~i~o~loe~s~)
                               Gasoline. let ~luel~        ~i~q@~qZ~&~4q"                                                           Ph~oto~c~r~I~e~m~ic:~W~S
                               Diesel fuel. kerosene. ~jr2 heating o~t~l
                               Other petroleum ~f~q@od~uc~zs (grease.              ~q~6q7~ts                       gap              Printing ink ~0qC~qc~z~@~'~q7~8q@
                                                      ~6q@~q5~@~7~q@                                            ~%~,~.~/               wood pres~er~va~u~ve (creosote)
                                                            ~v
                               Degrea~se~r~s ~to~ir engines. metal. d~r~iv~e~qwa
                               and ~garag~q-                                                                                 Lye or ca~, ~D~c ~s

                               Battery acid (e~l~lectroty~l~e)          ~&~2qU~6qQ~4                                                  Jewelry cleaners or ~me~t~a~i ~qW~c~sh~e~s
                               Rustproc~qi~qf~qe~qr~qs;                                               ~4q0~2q1~0q@~1~q-~4qa~4qi                       ~qL~qea~qc~qie~qr ~qdea~qr~ql~qers
                               Car v~qrash detergents. waxes. and polishes                             ~8q@~qI~8qj ~36q4~52qW               Pc~qe~qs
                               Aspha~qf~qt & roofing tar                                                                      Other ch~qlonnated hy~qdro~qca~qj. ~68q=~2q@~88q.~48q/
                                                                     ~40q(6~24qy~72qA                                                 including c~qar~qo~qon te~qtrac~qnIo~qn~qd~qe
                               Paint  ~.s. varnishes. stains. dyes                          ~q-~q;~04q@~00q4~q4~80qW                                                    ~q-PO~qI~qS~qO~qn~q'    ~32qc~6q4~08qa~qz~0qt~qa~qf~16qu
                                                                                                                          Any other products with               ~qla~qf~q"~q@~6q@
                               Pa~qk~qu & ~qla~qic~q;~qt~q:~qfu~qe~qir ~qr~qdnn~qe~qrs. paint b~qoush                                                   (~qin~qdu~qding c~qh~qlo~qrotorm. ~qtD~qrrr~qfa~qld~0q&ry~qde.
                               cleaners. a~qn~qd ~qf~qic~qlor ~q& ~qh~qKnrtu~qre ~qs~qa~8qWers                                                     hydrochloric acid. o~qa~qx~q-~qr acids)

                               Spot ~qre~4qm~4qw~qe~qr~qs ~q& ~qc~ql~qea~qn~qing fluids (dry                                                        O~qt~qh~qe~qir products not listed ~qw~qh~qi~ql~qc~qh you I"
                               d~qean~qe~qr~qs) ~q(~qx other ~qd~qea~qn~qing solvents                                                         may be toxic or hazardous (please List)
                               Cesspool cleaners                                                      ~qI~40qv~6q-

                                                         ~64qo~96qk~24qe~88qe~12qc~20qa~q'~20qQ~04q@~00qo                                                  -2-
 

~0

                      ~2. v~~~a~ type of wastes do you pr~odu~~7
                                  Type of                              Quantity                                  ~qO~qT~~q%~iMethod Used
                             Waste Prod                           Gener~tedfY



                                                 ~(~-~0qX~6q/
                                                                                                    ~qf~4 ~7 ~qt ~8qo~4qr~@~:  ~c~qo~l~!




                      Note: Contact the NH Wellhead Protection Program (271~-~q3431) ~Y~-~qith questions or concerns ~qm~q9a~rd~ing
                      reported disposal pr~acti~oe~a~.
                      Section Three: ~qIf the PC~qS is subject to the ~8qBMP rules, ask them the following questions to det~er~qmn~e
                      comp~ql~qi~qia~q@e during a ~q1~q3MP c~omp~qf~qiar~w~>~-~e inspection:

                                                   Storage of Regulated Substances (refer ~qto Env-W~qS 421.04)

                      Where are the regulated substances stored which were described in 6ec~qt~ion 2? (Describe here and/~or~:~E~;k~e~tch
                      on ~t~qhe back of I his form.)





                      Ask ~qth~e ~qf~o~ql~qlo~y~Ang qu~e~s~ql~qio~ns ~qto determine compliance with BMP Pile E~qM-W~q&G4~@

                        Yes No (~4qWA)

                      1~q)_ _ _             Is there an irn~qp~@~erv~qi~ou~s surface under the r~9gu~i~a~i~ed ~Bub~s~t~an~c~e~s~)
                      E~n~v-W~s 421~.04~q(b)    ~qH no, describe:



                      ~28q-
                      2)                  Is the storage are~a(~s) secured against unauthorized entry (i.e. bung l~o~ck~8~. surveillance~, etc p
                      ~4;52qr~.~-~-W~& 421~.~0~d~q(c)  ~q" yes. describe:


                      ~-3) - - -           Is the storage area(s) inspected weekly for signs of 8p~qills?
                      E~n~v-W2 42~1 ~1~0~0q@~d~q)

                      4) . . .            Is there sufficient space between large containers to allow for inspections?
                      ~'~qEn~v-We A21 ~DA~q(d)



                      ~'~q5) - - -           Are regulated substances which are stored outside covered~q@
                      ~qG~n~M~-~4qW3421.o4~q(~e~q)     If yes. describe:


                      ~'6) - - -           Are regulated ~aub~a~qtanc~e~8 which are ~B~qlored outside> 50 feet away from a surface water body?
                      Env-We 421.04 (1)

                      ~q'~72qn _ _ _            Are regulated substances which are stored outside > 75 feet away from a private well?
                      ~qE~qn~q%-W~qa 421


                                          Are regulated substances in outdoor storage areas stored outside the protective radius of
                      E~qn~qy~q-wz 42 ~qi~qo~q4 ~8q(f~8q)   public water supply w~qe~6qlls?~8q(Radius is usually 2~20qW or 4~20qW - o~qa~qn~qt~qa~qct 271~q-3431 with qu~qe~qet~2qion~qs.)

                                          Do outside storage areas containing an aggregate of > 275 gallons (5 drums) of regulated
                      ~4qE~qfw~q-~6qw~qa 42~q1 ~8qD4~8q(~4qg~2q)    substance have ~qs~qo~qoondary oontainmen~8qt ~4qC~qi~q.e~q- bem~qvs)?


                                                                                          -3-
 

~0


                                                                                                                  ~~0002










                            POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM



                 INSTRUCTIONS: This form should be o~omplet~ed for each P~0qC~qS. It should be updated as n~e~oe~ssary each
                 ti   an inspection of the po~qten~6qW~qI ~oonta~n~-~qdr~i~ati~o~'n source is performed.


                 P~0qC~qS INFORMATION


                 PC~qSNam~e:
                 Address:

                 Town:- ~'~0qV~q@~-~e~0qk~-~0qK ~q1U~8q#~c~)~2~,~q9~2q8? T~a.M.~2p:                                   Lot Number:



                 Ov~qm~er Name:       ~4qS ~r ~q, 7~6q7     ~2qf~2qi~ql ~8q0                              P~qfK~v~qw Number: ~0qj~qc~2q&
                 Addr~e~3s:
                                        ~r~c~q@ &I'"
                 Town:                                            Slate:                   Zip Code;


                 PC~qS ~6qQ~0q0NTA~2qQT PERSON INFORMATION: (comp~qic~qle only ~qi~qt different from above)

                 Contact Pe~r~8o~n:                                                    Phone Nurn~qb~er
                 Address~:


                 Town:                                            Slate:                   Zip Code:


                 PCS Type (see Est on back):             ~qt~qq tint-, .- ~8qi~8qd~ql~qu~8qo ~6qa~:~q3~4qa~q(~qA~4q"~2q5


                 SIC Code (s~q@ee PCS(~6qS~qIC matching tables in inventory guidance document):
 

~0






                                                    POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                             INSTRUCTIONS: S~e~qcti~qo~qm ~o~ne and two of this form should be completed for every inspection of a potential
                             c~or~qdam~qin~al~qion source ~q(~0qP~8qC~8qS~q) perfor~r~i~ned- Se~2qd~ion~s thre~-e and four should be completed for Best Management
                             Pr~a~qc~qti~lce~s ~l~qZ~qiO~(~6qWr~k~anc~e ~qIn~spe~c~qt~s~o~qm o~r~qdy.

                             S~qe~c~qItion One.

                             Date of I
                             Name of Potential Contamination Source (~qF~ICS~q):                                ~0qa~2qf ~0qa~qt~ql~4q@
                             Town PCS Located in:                      ~0q@~6qV~6qw

                             Inspec~qton Type (~ch~e~4qd~@ one)-
                             In~qi~6qW~qd Inventory Verification                ~8qj                         Blasi Management Practices C~o~r~npl~qianc-e
                             Name and Title of Pe~r~zon(s) Performing Inspection~:
                                                                                                               ~1~q7~, ~,

                             ~2qN~arr~i~qg~-~an~qd Title of P~er~ron(~s) Providing information about the PCS-
                                   ~q@~,C~c~-~)-~0q77~q- ~8q1~-~8qko~,- ~-~qS~~qS ~L~6qQ

                             Section Two ~4qDues~t~qions to ask ~the PCS repfesenta~irve ~to de~ie~rT~n~ine if they are a PCS subject ~to B~qMP ~r~ule~@~,
                               nv~-ws 421 ~q) because they use, handle, store. or dispose of ~(e~qgul~aie~d substances

                             ~1    What re~qoula~ted substances ~do you use. handle. or store) Please ~c~om~p~i~c~ie ~i~'~)~e lo~llo-~n~qo c~n~an 1~1
                             substance is not used. please -rrie N/A (Suggestion Lei ~t~he PCS rep~tesen~ia~i,~@~: 1~-~1i ~o~ui ~1~1~)e ~Cna~r~l I
                             Antifreeze (,of g~a~so~l~-~n~e o~(coo~la~n~i system)                 ~qOu                       D~s~,n~l~ec~ta~n~t~s                                           ~0 U an

                             A~:utomaDc ~tra~nsm~qms~io~n ~f~lu~-~d                                                         Road ~s~-~ar~t ~(~n~w~r~t~e~)


                                                                                                                 Ret~n~qWan~ts
                             &Vine ~& ra~(~uatc~i~s ~nu~s~n~e~s
                             Hydraulic ~Au~i~c~l (~i~r~K~Ju~di~ng brake fluid)                            ~q/~0qo               ~F~-er-~T~i~l~tz~er~s (~i~t stored outdoors I
                                                                                                                                         I

                             ~&~4~ot~o~t oi~ts~/wa~s~te ~o~g~i~s.                                                             Pe~s~t~i~c~3~oes ~q(i~ns~e~ct)~C~i~d~e~S. her~t~)~,~0~0~e~S
                                                                                                                 ro~c~se~n~ti~o~ces~)
                             Ca~sO~l~trbe. let ~tue~l                                                                 P~hot~oc~he~qmca~ts
                             Diesel fuel. kerosene. ~v2 ~h~ea~b~ng oil                                 ~qC~,~.~-~0q[~-         Prin~b~ng ink
                             ~()~Me~t petroleum products (grease. lubricants)                                       Wood preservative (creosote)                                            (A.,
                             Degre~a~ser~s to( engines. ~rneta~i. dri~ve~%~vay-s
                             and garages                                                                         Lye o~r caus~uc soda
                             Battery acid (e~l~ec~tro~4q"~e~q)                                          -~4~qr~6q@~q-             Jewelry ~c~i~q@s o~r ~n~e~m~J po~lts~h~es
                             Rust~p~r~oc~qite~r~s                                                      ~q1~2q0~-              L~qaa~t~he~qr cleaners
                             car wash detergents. waxes. aria p~qo~qh~qshe~qs                         ~q-~qA~4qE~4q@~q- ~0q-            ~qP~qc~qa~qs
                             A~qs~qp~qha~qf~qt &.roofing tw                                            ~48q6~qQ            ~q1~q>    Other chlorinated hydrocarbons
                                                                                                                 ~qL~qr~qK~qlu~qding carbon tetrachloride
                             Paints. var~qr~qiishes. stains. dyes                                                         I
                                                                                                                 Any other products with "Poison' La~qo~qe~qts
                             ~qP~qa~qk~qu &        uer runners. paint brush                                              (including chloroform. ~qlor~0qma~qi~qde~qhy~qo~qe~q.
                             d~qea~qne~qrs~q.        floor ~q& ~qh~qxn~qi~qt~qu~qr~qe strippers                          e               hydrochloric acid. o~qd~qwer acids)

                             spot removers a ~qc~qk~-~qj~q'~qa~qn~qin~qg fluids ~4q(~qC~qk~qy                                              other products not listed which you I"
                             deane~qrs) or o~qe~8qw cleaning solvents                                                   n~6qW be toxic or hazardous ~6q(please list)

                             Cesspool cleaners



                                                                                                            -2
 

~0

                       What type of wastes do you produce?
                                 Type of                            Quantity                                 ~qO~l~p~~~~l Method Used
                            Waste Produced                      Generatedlyear







                     Note: Contact the NH Wellhead Protection Program (271~-~0q3431) with questions or concerns regarding
                     reported ~2qd~qmpo~r~s~a~ql practices.
                     Section Three: ~qH the pC~4qS is subject to the. amp rules, ask them the following questions to det~er~r~in~in~e
                     co~r~np~qli~z~i~qnce during a ~q1~q3MP con-~6qptian~ce in~spe~c~qf~qb~i~qx

                                                 Storage of Regulated Substances (refer to ~qF~jw~-W~qS 421.0~,4)

                     Where are the regulated ~sub~s~qtan~c~e8 stored which were d~e~&~c~r~8qb~e~qd 'In section 2? (Describe h~er~u a n~qd/~qbr sketch
                     on ~qt~he back of this form,)




                     Ask ~qthe following qu~e~3~ql~qio~qm to de~ql~ermin~e compliance               w1l BMP rule E~nv-W~a.~q04:

                       Yes No (~8qN~q/A)

                                        Is there an impervious ~aurf~ac~a under the r~egu~qt~a~l~e~qd ~Bub~s~t~anc~,~9~9~9
                     ~En~v~-~V~V~9421.~0q"~b~j     ~q" ~no, describe:



                     ~28q_
                     2~q)~q_                Is ~the storage are~a(~s) secured against unauthorized entry (i.e. bung locks. surveillance, etc)?
                     ~;64qrw~-W~& 421.~04(~c)   If yes. describe.-


                     ~q3~q)~q_                Is the storage ar~ea(~s) inspected wee~ql~qdy for signs of spills?
                     Env-W.s ~421.~4q"d)
                     4) - - -           Is there sufficient ~sp~a~q@e between large containers ~qto allow for inspections?
                     *~qEnv-W~e A21 ~j~DA~q(d)



                                        Are regulated substances which are stored outside covered?
                     ~0qGW~-W~a 42~1~.04~q(~e)    If yes, describe:


                     ~*~q6) - - -          Are regulated substances which are ~B~qlo~red outside> 50 feet away from a surface water body?
                     Env-W~qs 4~q21.04 (f)

                                        Are regulated substances which are stored outside > 75 feet away from a private well?
                     ~2qSw~q-W~q& 4~q21~q.04 (~0qQ

                     ~q*~6q0~2q) - - -          Are regulated substances in outdoor storage areas stored outside the protective radius of
                     E~qn~qy~q-w~qz 421~q.04 (~qf)  public water supply wel[~6qL~qs?~6q(~16qRadiu~qs is u.Sua~6qHy 2~24qW or 4~24qW - c~qor~0qdact 271~q-3431 with que~qat~6qion~qs.)
                     ~q*~0q9~6q) - - -          Do outside storage areas containing an aggregate of > 275 gallons (5 dn~qim~qs) of regulated
                     E~qn-w~qo 421~q-04~8q(~4qg)    substance have secondary containment ~6q(~qLe- berms)?
 

~0







                                                   A~0qf~0qtachment 6
                                                    (Page 1 of 7)


                 POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM (DRA~0qFI-)




            INSTRUCTIONS: This form should be completed for each PCS~. It should be updated as necessary each
            time an inspe~qc~q6on of the potential cor-dan~-~tinat~qion source is performed.


            PCS INFORMATION:


            PCS Name:        ~qe~q) ~qU ~0qr~-~8qr
            Address:           I     cod, ~qt~- ~"~qa~qr~-

            Town:                                 Tax Map:                     Lot Number:


            P~4qQS OWNER INF~8qQR~4qMATION~:

                                                                                                  C~k
                           ~-~q)o ~6qL                                           Phone Number:           ~i
            OwnerName:         -~,,1~q4 ~2qC-~qp~ck~qj
            Address:          ~qt~-~L
            Town:       ~re ~V~, ~q-~q;~6q@ ~6q@~a~q@                      S~qta~qle~@ ~i~-~@             Zip Code: 03 ~0q&~q3


            PCS ~8qQQNTA~2qCT PER50N INFORMATION:       (complete only ~qd different from above)

            Contact Person:                                                 Phone Number:
            Address:


            Town:                                          State:                 Zip Code:



            PCS Type (see list on back):



            SIC Code (see PCS~qIS~qIC matching tables in inventory guidance document):
 










                                                                    Attachment 6
                                                                     (Page 2 of 7)




                                                   Potential Contamination Sources
                                    Subject to Compliance Inspections with Env-WS 421


                   Vehicle service and repair shops - including but not limited to: automobile, truck. and equipment service or
                   repair shops, autobody shops: and aircraft fueling, deicing, and maintenance areas.

                   General service and repair shops - including but not limited to: furniture stripping, painting. and refinishing
                   photographic processing. printing: appliance and small engine repair: boat repair. service. and refinishing.
                   refrigeration, heating. ventilating and air conditioning shops.

                   Metalworking shops - including but not limited to: machine shops.- metal plating, heat treating. smehing and
                   jewelry making shops.

                   Manufacturing facilities - including but not limited to: electronics and chemical manufacturing. processing.
                   and reclamation-. paper, leather. plastic, fiberglass, rubber, silicon and glass making'pharmaceutical produc
                   tion. pesticide manufacture-. and chemical preservation of wood and wood products.
                   Waste and scrap processing and storage - including but not limited to@ junkyards. sc'rap yards. and auio
                   salvage yards.- wastewater treatment plants.- dumps, landfills, transfer stations and other solid waste facilriies.
                   and wastewater or septage lagoons.

                   Laboratories and professional offices - including but.not limited to: medical, dental. and veterinary offices:
                   a4d research and analytical laboratories.

                   Salt storage and use - for winter road and parking lot maintenance.

                   Cleaning services - including but not limited to: dry cleaners, laundromats: beauty salons. and car washes.

                   Food processing plants - including but not limited to: meat par-king and slaughterhouses-. claines@ and
                   processed food manufacture.

                   Fueling and maintenance of excavation and earthmoving equipment

                   Concrete, asphalt and tar manufacture

                   Hazardous waste facilities - regulated under the Resource Conservation and Recovery Act, as imple-
                   mented by RSA 147-A.1 11.


~0


                                                                                         Attachment 6
                                                                                          (Page 3 of 7)
                                     POTENTIAL CONTAMINATION SOURCE INSPECTION FORM (DRAFT)

                       INSTRUCTIONS: Sections one a~nd two of                       this form should be completed for every inspection of a potential
                       contamination source ~q(P~8qC~2qS~q) performed. Sections three and four should be completed for Best Management
                       Practices Complia~r~v~ce inspections only.

                       Section One:

                       Date of Inspection:

                       Name of Potential Contamination Source (PCs):

                       Town PCS; Located          in:

                       Inspection Type (check one)
                       Initial Inventory Verification ~q@~8q@~4qZ                              Best Management Practices Compliance

                       Name and Title ~e~qd P~qe               ( ) Performin
                                                     ~6qP~2q?  n s               ~, g I sp, ion:
                                                         ~6qW ~6qd~qd~"~q@~q'

                       Name and Title of Person(s) P~r~o~vid~l                   Information about the PCS:


                       Section Two: Questions to ask the PCS representative to determine it they are a PCS subject to BMP nu~qles
                       (Env-Ws 421) because they use. handle. store, or dispose of regulated substances.
                       ~q1, What regulated substances do you use, handle, o~r store? Please complete he following cha~n, If ~1he
                       substance is not used, please write N/A. (Suggestion- Let the PCS representative fill ou~qt ~qlhe chart.)

                                                                               Quantity ~q(~qGa~l~q)                                                               ~Quan~n~ry (Gal)
                       Antifreeze (~lo, gasoline o~r c~ocan, system,                                      Disinfectants

                       A~mto~rnatic transmission fluid                                                   ~P~o~ad ~sa~i~t (ha~irt~e)

                       Engine ~& radiator Rushes                                                        Ret~n~ge~rants

                       Hydraulic fluid ~q(ffx~:~f~ud~ing brake fluid)                                        Fertilizers (it stored out~i~qm~rs~q)

                       ~qW~tor oi~l~s~twas~te oils                                                            Pesticides (~inse~cti~c~ides.~,herb~icides~.
                       ~C~'~qW~'~o~r~qm~. ~qi~e~t fuel                                                 ~0~0~C~)~0qN~qI        ro~denti~c~ides~q)
                                                                                                       P~hotoc~hern~ica~ls
                       Diesel ~f~L~x~A~. kerosene, ~02 heating ad                                            Printing ink
                       Other petroleum products (grease. lubricants)                                   Wood preservative (creosote)
                       D~ogr~ea~sers for engines. metal. driveways
                       and wages                                                                       Lye or caustic soda

                       Battery acid (electrolyte)                                                      Jewelry ~c~k~3an~ers or metal polishes

                       Rus~iproo~t~ers                                                                    Leather clearers

                       Car wash detergents. waxes. and polishes                                        P~cB~s

                       Asphalt & roofing tar                                                           Other chlorinated hydrocarbons
                                                                                                       including carbon tetrachloride
                       Paints. varnishes. stains. dyes
                                                                                                       Any other products with ~q"Poison~q"~qt~qab~qels
                       Paint ~q& ~00qW~qoqu~qer ~04qf~04qt~qv~qx~qxs. paint brush                                              (including chloroform. formaldehyde.
                       ~6q6~q3~qanor~qs. and floor ~q6 ~qf~qt~2q"~qit~qt~qire strippers                                        hydrochloric acid. other acids)

                       Spot removers & cleaning fluids (dry                                            Other products not listed w~00qNch you ~q1~2q"
                       cleaners) or other cleaning solvents                                            ~2qmay be toxic or hazardous (please list)

                       cesspool cleaners



                                                                                                   -2-
 





                                                                           Attachment 6
                     2. What type of wastes do you produce?                 (Page 4 of 7)

                                  Type  of                       Quantity
                            Waste Produced                   Generated/Year                            Disposal Method Used













                     Note: Contact the NH Wellhead Protection Program (271-1168) with questions or concerns regarding
                     reported disposal practices.


                     Section Three: If the PCS is subject to the BMP rules. ask them the following questions to determine
                     compliance during a BMP compliance inspection:

                                               Storage of Regulated Substances (refer to Env-WS 421.04)

                     Where are the regulated substances stored which were described in section 2'@ (Describe here and/or sketCh
                     on the back of this form-)





                     Ask the following questions to determine compliance with BMP rule Env-Ws.04
                     --,Yes No (NIA)

                     .1) - -      -    Is there an impervious surface under the regulated substances?
                     Env-Ws 421.o4(b)  If no. describe-



                     -2) - - -         Is the storage area(s) secured against unauthorized entry (i.e. bung locks, surveillance, etc.)?
                     Env-WS 421.04(c)  If yes. describe:


                     -3) - - -         Is the storage area(s) inspected weekly for signs of spills?
                     Env-WS 421.04(d)


                     -4) - - -         Is there sufficient space between large containers to allow for inspections?
                     Efw-Ws 421.04(d)


                     *5) . . .         Are regulated substances which are stored outside covered?
                     Erw-Ws 421.04(e)  It yes, describe:


                     *6) . . .         Are regulated substances which are stored outside > 50 feet away from a surface water body?
                     Erw-Ws 421.04 (Q

                     -1) _ _     -     Do outside storage areas containing an aggregate of > 275 gallons (5 drurns) of regulated
                     Env-Ws 421.o4(g) substance have secondary containment (i.e. berms)?


                                                                                 -3-


~0







                                                     Attachment 6
                                                      (Page 1 of 7)


                  POTENTIAL CONTAMINATION SOURCE (PCS~q) INVENTORY FORM (DRAFT)




            INSTRUCTIONS: This form should be completed for each PCS, It should be updated as necessary each
            time an inspection of the potential contamination source is performed.


            P~6qG~2qS INF~2qQRM~8qATION:

            PCS Name:
            Address'.      ~2qT~qI~q)

            Town:                                   Tax Map~@                      Lo~qt Number:


            PCS OWNER INFQRMATIQN:
            Owner Name:                         ~6q0~2q/~,~q@~0q@~0q@                        Phone Number
            Address.-


            Town:                                            S~qta~qte~i                   Zip Code:


            P~2qQS CONTACT PERSON INEORMATION: ~q(~complele only if different from above)

            ~4qCo~6qMact Person:                                                     Phone Numbe~v
            Address:


            Town:                                            State:                   Zip Code:


            PCS Type (see list on back):   ~8q1~6qV~_~,~0qb~,~q:~6qr~2qb~,~8qy~q6~qP~qj~q0~_~, ~8qo~6qk~2qd~0qx~6qL~6q@


            SIC Code (see PCS~q/SIC matching tables in inventory guidance documer~r~qi):
 









                                                                    Attachment 6
                                                                    (Page 2 of 7)




                                                  P otential Contamination Sources
                                   Subject to Compliance Inspections with Env-WS 421


                   Vehicle service and repair shops - includin    g but not limited to: automobile, truck, and equipment service or
                   repair shops, autobody shops. and aircraft fueling, deicing, and maintenance areas.

                   General service and repair shops - including but not limited to: furniture stripping. painting, and refinishing:
                   photographic processing-. printing.- appliance and small engine repair. boat repair, service, and refinishing
                   refrigeration. heating, ventilating and air conditioning shops.

                   Metalworking shops - including but not limited to: machine shops.- metal plating. heal treating. smelting and
                   jewelry making shops.

                   Manufacturing facilities - including but not limited to: electronics and chemical manufa  ciuring, processing,
                   and reclamation. paper, leather. plastic. fiberglass. rubber. silicon and glass making'pharmaceutical produc-
                   tion.- pesticide manufacture.- and chern-ical preservation of wood and wood products.

                   Waste and scrap processing and storage - including but not limited to: junkyards, scrap yards. and auto
                   salvage yards-, wastewater treatment plants. dumps, landfills, transfer stations and other solid waste facildies,
                   and wastewater or septage lagoons.

                   Laboratories  and professional offices - including but not limited to: medical, deMal. and veterinary off ices:
                   apd research and analytical laboratories.

                   Salt storage and use - for winter road and parking lot maintenance.

                   Cleaning services - including but not limited to: dry cleaners. laundromals: beauty salons-. and car washes.

                   Food processing plants - including but not limited to: meat packing and slaughterhouses.- dairies: and
                   processed food manufacture.

                   Fueling and maintenance of excavation and earthmoving equipment

                   Concrete, asphalt and tar manufacture

                   Hazardous waste facilities - regulated under the Resource Conservation and Recovery Act, as imple-
                   mented by RSA 147-A.1 11.


~0

                                                                                          At~ta~cn~qment 6
                                                                                            (Page 3 of 7)

                                     POTENTIAL CONTAMINATION SOURCE INSPECTION FORM (DRAFT)

                       INSTRUCTIONS: Sections one and two of this form should be completed for every inspection of a potential
                       contamination source (PCS) performed. Sections three and four should be completed for Best Management
                       Practices Compliance inspections only.

                       Section One:

                       Date of Inspection:
                       Name of Po~qtentia~ql~0qCo~qr~ttamina~qt~qion Source (PCS~q):                                     ~2qA~6qu

                       Town P~8qCS Located in:

                       Inspection Type (check one):
                       Initial Inventory Verification                                    Best Management Practices Compliance

                       Name and Title of Person(s) Performing Inspection:


                                 nd             Person(s) Providing Information about the P~qC~qS:~


                       S~8q&tion Two: Questions to ask the PCS representative to determine it they are a PCS subject to BMP rules
                       ~q(Env-Ws 421) because they use. handle, store, or dispose of regulated substances.
                       1. What regulated substances do you use, handle. or store? Please complete the lo~qllowing chart. If the
                       substance is not used. please write N/A. ~q(Sugges~qlio~qm Lei ~the PCS representative fill out ~the chart.)

                                                                                ~qO~u ~ty (Gal)                                                                               (Gal)
                       Antifreeze (for gasoline or coolant system)                                       Disinfectants                                                 ~ty

                       Automatic transmission fluid                                                      Road sa~it ~q(~na~irte~q)

                       Engine & radiator flushes                                                         R~et~n~ge~ra~nts

                       H~qyd~raL~d~i~c ~f~tu~id (including brake fluid)                                           Fertilizers ~q(~i~t stored outdoors)

                       ~qW~tor oi~ls~twas~te oils                                                              Pesticides (inse~c~t~a~des. herbicides,
                       Gasoline. jet fuel                                                                ro~den~d~c~3~d~es)
                                                                                                         Photoc~nemica~ks
                       Diesel fuel. kerosene. ~92 heating o~i~l
                       Other petroleum products (grease. lubricants)                                     Printing ink
                       De~qgreasers for engines. metal. driveways                                          Wood preservative (creosote)
                       and garages                                                                       Lye or caustic soda

                       l~qaam~qm acid ~q(electrolyte~q)                                                          Jewelry cleaners or metal polishes

                       ~R~u~s~t~pr~o~o~te~rs~                                                                     Leather cleaners

                       Car wash detergents. waxes, a~nd polishes                                          PcB~s

                       Aspha~qf~qt ~q& roofing tar                                                             Other chlorinated hydrocarbons
                                                                                                         including carbon tetrachloride
                       Paints. varnishes, stains. dyes
                                                                                                         Any other products with "Poison' ~qtab~qe~qLs
                       Paint & Lacquer ~qt~qh~qin~qn~qers~q. paint brush                                             (including c~4qNoro~qto~qn~qn, ~qformak~qsehyde.
                       cleaners, and floor ~q& ~0qtur~qi~q-~0qi~ql~qtu~qre s~q1~qr~0qipper~qs;                                      hyd      ~qo~qr~qi~qc acid. other acids)

                       Spot removers & cleaning fluids (dry                                              Other products not listed which you tool
                       cleaners) or other cleaning solvents                                              rna~qy be toxic or hazardous (please fist)

                       cesspool cleaners
 





                                                                               Attachment 6
                       2- What type of wastes do you produce?                   (Page 4 of 7)

                                   Type of                          Quantity
                             Waste Produced                     Generated/Year                              Disposal Method Used













                       Note: Contact the NH Wellhead Protection Program (271-1168) with questions or concerns regarding
                       reported disposal practices.


                       Section Three: If the PCS is subject to the BMP rules, ask them the following questions to determine
                       compliance during a BMP compliance inspection:

                                                  Storage of Regulated Substances (refer to Env-WS 421.04)

                       Where are the regulated substances stored which were described in section 2? (Describe here and/or sketch
                       on the back of this form.)





                       Ask the following questions to determine compliance with BMP rule Env-Ws.04:

                       -Yes No (N/A)

                       .1) - - -         Is there an impervious surface under the regulated substances?
                       Env-Ws 421.04(b) If no. describe-



                       -2) - - -         Is the storage area(s) secured against unauthorized entry (i.e. bung locks. surveillance, etc.)?
                       Env-Ws 421.04(c) If yes. describe:


                       -3) - - -         Is the storag  e area(s) inspected weekly for signs of spills?
                       Env-Ws  421.04(d)


                       -4) _ _ -         Is there sufficient space between large containers to allow for inspections?
                       Env-Ws 421.04(d)

                       *5) . . .         Are regulated substances which are stored outside covered?
                       Env-Ws 421.04(e)  If yes, describe:


                       *6)               Are regulated substances which are stored outside > 50 feet away from a surface water body?
                       Ezw-Ws 421.04 (Q

                       -n - -      -     Do outsid  e  storage areas containing an aggregate of > 275 gallons (5 drums) of regulated
                       Ejw-Ws 421.o4(g)  substance have secondary containment (i.e. berms)?


                                                                                        3-


~0










                         POTE~2qN~2qnAL CONTAMINA~4qMN SOURCE (PCS) INVENTORY FORM



               INSTRUCTIONS: This foff~n should be ~o~omplet~ed for each ~qP~0qG~qS~. ft ~s~qt~kould be updated as necessary each
               time an inspection of the potential ~oontarn~qination source is performed.


               P~0qC~qS INFORMATt
               PC~qSName:                             ~8q@4~0q4~q7 ~L~r       ~/~1~,~qC~,
                                ~-~8q4 ~Z~7
               Address:                           I

               Town:                    ~@~4q4~/~/~qJ~,    Tax ~4qM~,~2p:                 Lot Number


               P~2qQ~q8 OWNER IN~qFORMATIQN:
                                                                                          ~qY~,
               Owner Name:                                              Phone Number.
               Address:

               ~qTo~v~v~n:~q-                                    State: ~4qt~-~1~1 ~2qX        ~0qZpC~od~e~.


               ~2qPC~q;~qS ~2qQ~6qQ~0qNTA~8qQT PERSON INFORMATION: (complete o~2q* ~qd d~qi~qf~qt~er~ent from above)
               Contact Pen~son:     ~2qo~8qz~6qM~q0~q,                                 Phone Number
               Address:


               Town:                                      State:               Zip Code:


               PCS Type (see list on back): ~6qQ~q@~8q@


               SIC Code (see IPC~qS~qI~qS~qIC matching tables in inventory guidance document):
 

~0






                                                POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                          INSTRUCTIONS: Sections one and two of this form should be ~o~ompl~eted for every inspection of a potential
                          ~c~o~r~i~l~qt~a~im~qir~t~a~qt~qion source (PC~2qS) perf~orn-~ted. Sections three and four should be completed for Beat Management
                                                ~k~-~inc~t~s ~qIn~spe~2qd~oo~4qm only.
                          Pr~qac~qt~ic~-es ~0qC~qO~qf~qf~0qp~qr

                          Se~c~qUon One:
                          Date of Inspection:                 ~q5 ~qJ~8qJ~P~0q3

                          Name of Potential Contamination Source (PCS~q):~

                          Town PCS Located in-

                          Inspection Type (check one):
                          ~qIn~qK~qL~-~qd Inventory V~e~qd~qf~qi~c~E~qd~qion                                     ~qE~qt~es~t Management Practices Compliance

                          Name and Title of P~e~qm~)n~qf~s) Performing Ins                           ~.  ~:
                                                      ~0q0~0qA~qt~q1~2q2~:~q&~8qR I ~q@                   ~0q=~r~-~qt~8q=~4qa

                          Name and Title of P~er~ron(~s) Providing Information about the PCS-


                          Section Two~@ Dues~t~@ons ~to ask the PCS represen~ta~irve to de~ferTn~ine if they are 4~3 PCS su~t~)~l~e~c~l ~l~o ~q@~q@~qY
                          (Env-WS 421) because they use, handle. store, or dispose o~f re~qgula~t~e~o substances

                          I   What regulated Substances do you use. handle, or store? Please ~c~,~0m~Qle~ie ~i~ne lollo~w,n~(~q;
                          u~q0s~iance is no~t used. please wrne N/A (Suggestion ~L-e~i ~t~he PCS ~(ep~resen~iai~ive ~'~,i~t ou~t ~ir~)~(~!

                                                                                 ~qoua~n~t~i~ry ~~t~c~@~a~i~)
                          An~o~r~reeze ~qvo~r ~g~a~so~4~ine or coolant system)                 ~6qj~-3~q;--~,~q5              Ds~in~te~c~i~ant~s,

                          ~,~qr~v~u~t~oma~dc trar~ts~qm~qm~s~io~n ~f~lu~-~0                                                   ~Roa~c~t ~sa~n ~(~r~%~a~j~i~L~e~)

                          Engine ~& radiator flushes                                                       ~Re~t~n~9~era~n~ts

                          Hydraulic fluid (including Wake fluid)                                          ~F~-ert~i~l~uers (it ~s~tore~a oux~toor~s~)

                          lV~io~to~(oils~i~waste oils                                                          Pes~t~i~o~oes ~qo~n~sec~o~qwe~-, ~r~-e~m~o~o~e~s~
                          C-tsotine. jet ~h~x~A                                                              rc~denti~c~i~o~es~)
                          Diesel fuel. kerosene. ~r2 hea~b~ng o~i~l                                            P~hot~o~c~he~qmica~is
                                                                                                          printing ink
                          0~1her petroleum products (grease. lubricants)                                   Wood preservative (creosote)
                          Degr~ease~f~s for e~n~gi~t~,~,es. metal. driveways
                          and garages                                                                     Lye o~(c~a~u~s~t~)~c soda


                          ~Ba~r~te~t~y acid (e~6ectrotyte~q)                                                      ~J~e-e~try c~l~ea~n~e~fs or meta~j ~q"~i~sh~es


                          Rus~qtproo~le~qr~qs                                                                    Leather c~qle~8q@


                          Car wash detergents. waxes. and polishes                                        Pc~qa~qs

                          Asp~qha~qf~qt ~q& ~qfoofi~qng tar                                                           Other chlorinated hydrocarbons
                          Paints. va~qrr~qishes. stains. dyes                                                 including carbon te~qi~qra~qc~qn~qio~qn~qd~qe
                                                                                                          Arty o~qv~q%ef products with 'Poison' ~qta~qbe~qts
                          Pak~qa & ~qL~qi~6qNue~qr ~qV~q*~qv~qx~qws. paint brush                                               ~6q(~qinclu~qdli~qng chloroform, to~qn~q-na~qk~qsehy~qde.
                          c~q9~qean~qe~qr~qs. and floor ~q& ~qK~qf~qf~qn~qi~qt~qi~qr~qe s~qtripp~qe~qfs                                       ~qhy~qdf~qo~qchlo~qnc acid. other acids)

                          Spot ~qre~qa~ql~qo~qvec~qs & c~qlean~qk-~qg fluids (dry                                           Other products (tot lis~qs~ql~qed which you feel
                          cleaners) or o~ql~qh~qer cleaning ~qso~qt~qvents                                            ~0qm~qay be ~qt~qo~q6~qc or ~qt~4qQ~4q=~qdous (please t~qi~qs~qt)

                          C;e~q@spool cleaners



                                                                                                     -2-
 

~0

                   2- V~VIhat type of wastes do you produce?

                              Type of                        Quantity
                         Waste Produced                   G~ner~a~ted~lyear                          D~L~~qNs~~l Method Used
                               ~q0~4 ~C~q-                         ~q1,~P~~a~qa~ ~e ~ ~-                   ~i~b ~b               Hal      ~6~~~@
                          4~1~1~, -,-1,                  ~q-~6q=       ~.~0~8q0                     ~t~qV~-~'~2~7~-~'~-~q6                     ~~1~q1~6                    ~j~.~8qT~0qs
                         ~t~q ~A~1~,~7~-~q1                                                              ~C~.~-~q V

                       ~q/~2qN~8q2~6q2~q2~1~:~qf
             ~~qq

                   Note: Contact the N~2qH Wellhead Protection Program (271,3431) with q~u~e~s~qf~ion~s or concerns regarding
                   reported ~c~q9~spo~s~al practices-
                   Se~c~q6on Three: ~qIf the P~2qC~4qG is subject to the ~2qOMP rules. ask them the following questions to de~qt~e~r~n~-~q@ni~a
                   co~qmp~qlia~r~ice during a ~4qBMP co~r~r~tp~qHa~r~v~q,~-~-~- inspection-

                                            Storage of Regulated Substances (refer to ~qF~-~n~V-W~qS 421.04)

                   More are the regulated substances ~s~qlor~ed which were described in section 2~*~) (Describe hem and/or sketch
                   on the back of this form.)





                   Ask ~qthe following qu~6~s~ql~q@ons ~qto determine compliance ~4qMh BMP rule Env-W~s.~q04

                    Yes No (~2qWA)

                   1~q)_ _ _          Is there an in-pervious surface under the regulated ~8ub~a~t~a~nc~e~s~')
                   En~v-W~3 421~.0~4(b~q) If no, describe:



                   ~32q-
                   2)               Is the storage ~are~a~q(3) secured against un~a~qwhor~qiz~ed entry (i.e. bung ~qk~x~-k~,~,~s. ~surve~i~l~ql~m~r~vce. etc.)?
                   ~;60qr~,~,-~-W~a ~42~i.o~4~q(c~q) If y~a~s~, describe:


                   3)               Is the storage ~a~qma(~s) inspected weekly for signs of spills?
                   E~nv-W2 421~.~0q"d)

                   4) . . .         Is there sufficient space between large containers to allow for inspections?
                   ~*~qEn~v-W~r, 4~21 ~A~)~4~q(d)



                      - - -         Are regulated substances which are stored our~ql~s~qide covered?
                   ~qEfW~-W3 421.04~q(0~q) It yes. describe:


                   ~*~q6~q) - - -        Are regulated substances which are stored out-side > 50 feet away from a surface water body?
                   En~qv~q-W~q& 421.04 (~6q0

                   ~q*~4q7) _ - -        Are regulated ~qsubstance~qs which are stored outside > 75 feet away from a private well?
                   ~qE~4qM~q-Wa 4~q21.~6q" ~4q(f)

                                    Are regulated ~qsub~qsiances in ourtdoor storage areas stored oL~0qas~4qid~qo the protective radius Of
                   E~qny~q-W~qs 421.04 (~6qQ public water supply we~6ql~8qt~qs?~2q(~16qRad~2qius is usually 2~8q0~8q0~qr or 4~20qW - contact 271~q-3~6q431 with questions.)

                   ~q*~0q9~6q) - - -        Do outside storage areas containing an aggregate of ~q> 275 gallons (5 drums) of regulated
                   ~4qE~qnv-w~qa 42i~qa~qd~2q(~8qq~2q)  substance have ~qs~8qooonda~qry oo~qn~2qtainmen~8qt (i.e. berms)?
 

~0








                      POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM



           INSTRUCTIONS: This form should be completed for each PCS. It should be updated as necessary each
           time an inspection of the potential ~qcon~qtarni~nation source is performed.


           PCS INFORMATIQN:
           PCS Name: ~'~qr~2q@~6qy~qe~4q@~4qC~2qK                                              ~0qT~8q@~' ~0q6~q0 ~8qb~qe~0q4~qc~q)
           Address:
           Town:    E~2ql~, ~0q6~4q1 ~qC                       Tax Map:                       Lot Number

           PCS OWNER INFORMATION:                                                    ~q6~q?~q0 ~q3    ~qe~-~8qV~I
           Owner Name:                                            ~0qV          Phone Num~t~)er
           Address.                            ~qt~qy     ~q)~0q7~'         1       ~2q& ~qe~-
                                               I          ~ ~'~q@ ~2qq~,  ~0q6~/~1~X    ~6q6~4qZ~0qA ~q- ~
           Town-,                                           Slate-.                  Zip Code


           PCS  QQNTACT PERSON INFORMATION: (complete only i~qt ditieren~qt from above)
           Contact Person:    S+~qe~q,~q)                  I ~6q9~.~7~2q6~8qC~1~4q1~0q0               Phone Number
                                        ~0qp~e      ~q:~8qd~q2                                           ~-~q?~,~,~q) - ~q(~qe ~6q5
           Address:                                  ~r~q9


           Town:                                             State-.                 Zip Code:




           PCS Type (see list on back):



           SIC Code (see PC~8qS~q/SI~8qC matching tables in inventory guidance document):
 












                                               Potential Contamination Sources
                                Subject to Compliance Inspections with Env-WS 421


                Vehicle service and repair shops - including but not limited to: automobile, truck, and equipment service or
                repair shops, autobody shops: and aircraft fueling, deicing, and maintenance areas.

                General service and repair shops - including but not limited to: tum4ure stripping, painting, and refinishing:
                photographic processing: prinling@ appliance and small engine repair: boat repair, service, and refinishing:
                refrigeration, heating, ventilating and air conditioning shops.

                Metalworking shops - including but not limited to: machine shops.- metal plating, heat treating, smelting and
                jewelry making shops.

                Manufacluring facilities - including but not limited to: electronics and chemical manufacturing, processing,
                and reclamation.- paper. leather. plastic. fiberglass, rubber. silicon and glass making-. pharmaceutical produc-
                tion-, pesticide manufacture: and chemical preservalion of wood and wood producls

                Wasle and scrap processing and slorage - including bul noi Jimiied ici lunkyards, scrap yards, and auto
                salvage yards. wasiewater treatment plants.- dumps, landfills. transfer stations and other solid waste facilities.
                and wastewater or seplage lagoons.

                Laboratories and professional offices - including but not limited to. medical, dental. and veterinary offices.
                and  research and analytical laboratories.

                Salt storage


                Cemetaries - if chemicals stored on she-


                Cleaning services - including but not limited to: dry cleaners, laundromats@ beauty salons: and car washes.

                Food processing plants - including but not limited to: meat par-king and slaughterhouses-, dairies; and
                processed food manufacture.

                Fueling and maintenance of excavation and earthmoving equipment

                Concrete, asphalt and tar manufacture

                Hazardous waste facilities - regulated under the Resource Conservation and Recovery Act, as imple-
                mented by RSA 147-A.1 11.


~0



                                         POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                   INSTRUCTIONS: Sections one and two of this form should be completed for every inspection of a potential
                   contamination source (PCS) performed. Sections three and four should be completed for Best management
                   Practices Compliance Inspections only.

                   Section One:

                   Date ~qof Inspection:

                   Name of Potential ~8qCon~qdamination Source ~q(PCS~q):

                   Town PCS Located in:

                   Inspection Type (check one):
                   Initial Inventory Verification                                  Best Management Practices Compliance

                   Name and Title o~qf Person(s) Performing In e~c~qt~q!~4qqn~:


                   Name and Title of Person~q(s) Providing ~qlnio~,m ion about the PCS:
                                  ~qC~j ~qr
                                         ~q4~qt~qZ                      ~4q66~2qD      ~qe~4qZ

                   Section Two: Questions to ask the PCS representative to determine if they are a PCS subject ~qto BMP rules
                   ~(Env-Ws 421) because they use. handle. store. or dispose of regulated substances.
                   1. What regulated substances do ~qy~ou use. handle, or s~qtor~8q0 Please complete the following charl If ~qthe
                   substance is not used, please wr~qhe N/A (Suggestion Let the PCS representative fill out the cha~r~l.)

                                                                                                                                                      Q~ua~nt~i ~t~q)~q@ ~(~C~-a~i~)
                   Ant~itreeze (~to~( gasoline or coolant system)            ~c~l~u                     Disinfectants

                                                                                                  Road Sall (ha~Jite)
                   AulD~rna~tic transmission ~lu~id


                   Engine    rad~Lator flushes                                                     ~Re~tr~ige~(an~i~s

                   Hyd~!~au~bc fluid (including brake fluid)                                         Fertilizers (i~l stored outdoors)

                   ~qWtor o~0qf~0qt~1was~te oils                                                            Pesticides (inse~c~t~cides. herbicides.
                                                                                                  roden~t~ici~d~es)
                   Gasoline. jet ~tu~e~l
                   Diesel fuel, kerosene. ~v2 heating oil                                          P~hotoc~h~omica~Js
                   Other petroleum products (grease. lubricants)                                  Printing ink
                                                                                                  Wood preservative (creosote)
                   ~0--greasers for engines. metal. driveways                                      Lye or caustic soda
                   and garages

                   Battery acid ~q(e~i~ectro~ty~l~e~q)                                                     Jewelry cleaners of metal polishes

                   Rustproo~le~rs                                                                   Lea~t~t~-~ef cleaners

                   ~Car wash de~u~Kg~qmt~s. waxes. and po~rtsh~es,                                        PcB~s

                   ~qA~q.spha~ql~qt & roofing tar                                                         Other chlorinated hydrocarbons
                   Paints. varnis h~qes. stains. dyes                                               including carbon tetrachloride
                                                                                                  Any other products with -Po~qis~8qw~q- labels
                   Paint & ~qL~qi~6qcq~8que~qr t~qhi~2qg~4qn~qo~qrs.~q. paint brush                                         (inclu~qdfi~qng chloroform. formaldehyde.
                   cleaners. and floor & furniture stripp~qe~qr~8qg                                      hydrochloric acid, other acids)
                   spot removers & c~qlear~qting fluids (dry                        PA.               Other products not listed which you feel
                   ~qc~qle~qan~qe~2qm~4q) of o~qth~qe~qir cleaning ~qso~ql~qi~qv~qents                                          ~6qm~04qW b~qe to& or hazardous (please list)

                   Cesspool cleaners



                                                                                              ~q-2~q-
 




                   2- What type of wastes do you produce?

                               Type of                         -Quantity
                          Waste Produced                   Generated/Year                             DispospItAethod Used







                   Note: Contacl the NH Wellhead Protection Program (271-3431) with questions or concerns regarding
                   reporied disposal practices.

                   Section Three: If the PCS is subject to the BMP rules, ask them the following questions to determine
                   compliance during a BMP compliance inspection:

                                             Storage of Regulated Substances (r er to Env-WS 421.04)

                   Where are the regulated substances stored which were descri              ed in section 2*7 (Describe here and/or skeich
                   on the back of this form.)





                   Ask the following questions to determine compliance with BM              rule Env-Ws.04
                     Yes No (N/A)    is there an impervious surface under the re lated substances'@
                   Env.Ws 421.04(b) If no. describe:



                                     Is the storage area(s) secured against una horized entry (i.e. bung locks. surveillance. eic
                   Erw-Ws 421.04(c) If yes, describe:


                   -3)               Is the storage area(s) inspected weekly f r signs of spills?
                   Env-Ws 421-04(d)


                   -4)               Is there sufficient space between large          rTtainers to allow for inspections?
                   Erw-Ws 421.04(d)


                                     Are regulated substances which are s ored outside covered?
                   Env-Ws 421.04(e)  If yes, describe:


                   *6)               Are regulated substances which ar stored outside > 50 feet away from a surface water body?
                   Env-Ws 421.04 (Q


                   *7)_              Are regulated substances which are stored outside > 75 feet away from a private well?
                   Env-Ws 421.04 (0

                   *8)_ - -          Are regulated substances in            oor storage areas stored outside the protective radius of
                   Ejw-Ws 421.04 (0  public water supply wells?(R dius is usually 200'or 400'- contact 271-3431 with questions.)
                                                                                 'y
                                                                                ,/er
                                                                                  or













                   '9)-              Do outside storage areas         r-daining an aggregate of > 275 gallons (S drums) of regulated
                   Gw-ws 42iw(g)     substance have seconda containment (i.e. berms)?


                                                                                  .3-


~0


                                                     Appendix II






                     POTENTIAL CONTAMINATION SOURCE (PCS) INVENTORY FORM




           INSTRUCTIONS: This form should be completed for each PCS~. It should be updated as necessary each
           time an inspection of the potential contamination source is performed.


           PCS INFORMATIQN:
           PCS Name:     ~6q&A~4qR~0qV       ~8q6~2qLA-~2qK-~0qe
           Address~@                   ~qh ~V~0qK~qT~4q& ~0q&~q&~qr~4qR
           Town~@                   ~i~qr~qt~-~q@~q4        Tax Map:                     Lo~i Number


           PCS OWNER INFORMATION:

           Owner Name:                                                   Phone Number ~4qb~8qo
                        ~6qC~n~qi ~qA~2qX
           Address    ~qr


           Town:                                          State:                 Zip Code



           PC~q5 CONTACT PEBSQN INFORMATION: (complete only it different irom above)
           Contact Person: C ~qA~-~qt~qA ~0qC~,~q@~2q@    ~2qg~4qC~2qf~2qt~2qq~q=~q-                         Phone Number~0qb~0qo ~-~q3 -7~,~,~:~8q6~q-
           Address:


           Town'.                                         ~qS~-~q1 ate:               Zip Code


           PCS Type (see list on back): ~4qV~6qd~o~u~2q@


           SIC Code (see PCS~qIS~qIC, matching tables in inventory guidance document):
 












                                                Potential Contamination Sources
                                 Subject to Compliance Inspections with Env-WS 421


                 Vehicle service and repair shop's - including but not limited to: autornobile. truck. and equipmeat service or
                 repair shops, autobody shops; and aircraft fueling, deicing, and maintenance areas.

                 General service and repair shops - including but not limited to: furniture stripping. painting, and refinishing:
                 photographic processing. printing.- appliance and small engine repair; boal repair, service, and refinishing.-
                 refrigeration,.heating, ventilating and air conciftioning shops.

                 Metalworking shops - including but not limited to: machine shops: metal plating. heat treating, smelting and
                 jewelry making shops.

                 Manufacturing facilities - Including but nol limited to,- electronics and chemical manufacluring, processing,
                 and reclamation- paper, lealher. plastic. fiberglass. rubber. silicon and glass making: pharmaceutical produc
                 lion.- pesticide manufacture. and chemical preservation of wood and wood producls

                 Waste and scrap processing and s1orage - including but not limited to- junkyards. scrap yards. and auto
                 salvage yards, wasiewaler treatment plants. dumps, landfills. transfer stations and other solid waste facilities.
                 and wastewater or septage lagoons.

                 Laboratories and professional offices - Including but not limited to: medical, dental. and veterinary offices.,
                 and research and analytical laboratories.

                 Salt.storage


                 Cemetaries - if chemicals stored on site.


                 Cleaning services - including but not limited to: dry cleaners, laundromats; beauty salons, and car washes.

                 Food processing plants - including but not limited to: meat packing and slaughterhouses.- dairies, and
                 processed food manufacture.

                 Fueling and maintenance of excavation and earthmoving equipment

                 Concrete, asphalt and tar manufacture

                 Hazardous waste facilities - regulated under the Resource Conservation and Recovery Act, as imple-
                 mented by RSA 147-A.1 11.


~0



                                        POTENTIAL CONTAMINATION SOURCE INSPECTION FORM

                  INSTRUCTIONS: Sections one and two of this form should be completed for every inspection of a potential
                  contamination source (PC~8qs) performed. Sections three and four should be completed ~qfor Best Management
                  Practices Compliance Inspections only.

                  Section One:

                  Date of Inspection:
                  Name of Potential Contamination Source (PCs): ~q-~qs~0qz~0qo

                  Town P~6qCS Located in:

                  Inspection Type (~qche~q(~6q* one):
                  Initial Inventory Verification                                   Best Management Practices Compliance
                  Name and Title of        Person(s) Per~qfo~r~qm~8ql~qinspection:
                                                   ~4q2~0q4~8q@~4                    I ~2qr~2qp~6q@
                  Name and Title of P~qq~rson~q(s) Providing Information about ~the PCS~:
                  ~ C ~2q9 ~2qU ~qr~, ~2qK ~4qL~-~6qb ~2qR~4qA~qr~, A~-~qh ~8qE~4qF-                               ~6qS~6qe~qz~qt~qy~0qJi~0qL ~6qe "It",

                  Section Two: Questions to ask the PCS representative to determine if they are a PCS sub~qlec~ql to BMP rules
                  (Env-Ws 421) because they use. handle, store. or dispose of regulated substances
                  1. What regulated substances do you use. handle. or store? Please complete the following charl It ~qthe
                  substance 'is not used, please w~r~qae N/A~(Suggestion. Let ~the PCS representative till out the chart.)
                                                                           ~qoua~n~D~ry ~q(~Ca~i~)                                                                Ouan~t~j~r~)~6q@~G~a~l~)
                  Antifreeze (for gasoline or coolant system)                                      Disinfectants
                  Automatic transmission fluid                                                     Road salt (halite)                                        ~q1~2q9~1~4q4
                  Engine & radiator flushes                                    ~qk~r~qq                 ~Re~t~n~gefants                                               k~q) A

                  Hy~dra~qu~N~c~c fluid (inc~lud~qin, brake ~luid)                                           Fertilizers (if stored outdoors)

                  ~Wtor oils~/waste oils                                                             Pesticides (i~n~sec~oci~des, her~bi~c~3des.
                  ~C~@as~o~l~4~q*~, jet tue~l                                              ~2qa~-A              r~odent~i~ci~des)                                             "A
                  D~o~ese~l t~ue~i~. kerosene. ~#2 heating oil                          ~0qA~i~-A              Photoch~emi~ca~l~s                                            ~.~q4~-~q)~6qA
                  Other petroleum products (grease. lubricants)                  ~0qA~8qJ~4qA               Printing ink                                               ~q/~-~0q4
                                                                                                   Wood preservative (creosote)
                  ~0--g~reaser~s for ~engi~r~-~es. metal. driveways                       ~0q2
                  a~nd garages                                                                      Lye or caustic soda
                  Ba~n~e~ty acid (electrolyte)                                                        Jewelry cleaners or metal polishes                        /~1~8qj~1~2qA

                  Rus~tpr~oofers                                                                     L~ea~t~l~-~@~-~-~r cleaners

                  caf wash detergents. waxes. and polishes                                         PCB~S
                  ~A~qsp~ql~8q@ & roofing tar         ~q-                                  "A                Other ch~qlon~qna~qted hydrocarbons
                  Paints. varnishes, stains. dyes                                ~36qL~00qM                including carbon ~qb~qe~qtrachl~qor~qi~qde                            ~28q^~12qA~8qj
                                                                                                   Any other products with 'Poison- labels
                  Paint~. & ~qL~04q"uer th~qinr~qw~qir~qs.. paint brush                                           (~qir~qicluding ~qd~q'~qd~qoro~qto~qrm~q, formaldehyde~q.
                  cleaners. and row & ~4qh~qa~04qWtu~qr~qe strippers                                            hydrochloric acid. other adds)                            ~44qAA.-

                  Spot ~qr~qem~qove~qcs ~q& cleaning fluids (dry                                             ~6qO~qd~qw~q.~qK products not listed which you fed
                  cleaners) or other ~qc~0ql~qea~qn~8qk~04qV solvents                                              ~0qmay be ~qtDx~0qic or hazardous (please list)
                  Cesspool cleaners                                              ~6qlu~ql~60qk


                                                                                               ~q-2~q-
 

~0


                                                                                                  ment of Commerce
                    2. What type of wastes d~ Y~u P~~Odu~e~~                        ~qN~qUS Depart
                                                                                    OAA Coastal Services Center ~qL~q@~q@~qb~ary
                                                                                   223~4 South Hobson Avenue
                                Type of                           Quantrl~y         C~ha~~l~~ston
                           Waste Produced                      GeneratedrYear                       ~'   S~qCID
                              AA~qJ ~qT~q? ~0qF~8ql~qJ~i~q@~4qC ~Z~-~-~8qe                                                                                              ~qhh~Y~L~qI~C~V~,

                                                                                          ~8qC~I~8qM~q4



                    Note: Gon~qfac~qt the NH Wellhead Protection Program (271~-3431) with questions or concerns regarding
                    reported disposal practices-
                    Section Three: It the PCS is subject to the BMP rules. ask them the ~qfo~qllow~,~ng questions to determine
                    compliance during a BIVIP compliance inspection:

                                               Storage of Regulated Substances (refer to Env-WS 421.04)

                    Where are the regulated substances stored which were described in section 2~q9 (Describe here and/or sketch
                    on the back of this form.)





                    Ask the following ques-~qt~ions to determine compliance with BMP rule Env-Ws 04

                      Yes No (N~q/A)


                    .1) ~q- ~q-      ~q-    Is there an impervious surface under the regula~qt           ed subs~tances~'~@
                    Env-Ws 4~q21.04(b)  It no, describe:



                    ~-2~q)~~q"             Is the storage area(s) secured against unauthorized entry (i.e. bung locks, surveillance, e~tc
                      7~--
                    En~v~,-Ws 421~.04(c) If yes, describe:



                    ~'3) - - -         Is the s~lorage area(s) inspected weekly for signs of spills?
                    E~nv-Ws 421.04(d)

                    ~-4)               Is there sufficient space between large containers to allow ~qfor i           nspec~qtions?
                    Env-W~S 421.04(d)


                    ~*~q5)               Are regulated substances which are stored ou~qlside covered?
                    E~nV-Ws 421~.04(e)  If yes, describe:


                    ~*6) . . .         Are regulated substances which are stored outside > 50 feet away from a surface water body?
                    Env-Ws 421.04 (~q0


                    ~q'7) . . .         Are regulated substances which are stored outside > 75 feet away from a private well?
                    E~qnv-Ws 421.04 (~0qQ

                    ~q*8)               Are regulated substances in outdoor storage areas stored outside the protective radius of
                    Env-Ws 421.04 (~0qQ  public water supply wells?~0q(Rad~qius is usually 200~q'or 400~q'~q- contact 271~q-3431 with questions.)

                    ~q.9)
                                      Do outside storage areas containing an aggregate of > 275 gallons (5 drums) of regulated
                    E~qiw~q-W~qs 421.04(g)  substance have secondary containment (i.e. berms)?
                                                                                                            ~2q=~-~qP~0q"

























                                                                                     -3-
 