Response Action Outcome Form
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2New Jersey Department of Environmental Protection
Site Remediation Program
RESPONSE ACTION OUTCOME FORM
Date Stamp
(For Department use only)
SECTION A. SITE
Site Name: ________________________________________________________________________________________________
Program Interest (PI) Number(s): ____________________________________________________________________________
Case Tracking Number(s) for this submission: _________________________________________________________________
This form must be attached to the Cover/Certification Form
All Oversight Invoices and Annual Remediation Fees are Paid in Full.
SECTION B. SCOPE OF THE RESPONSE ACTION OUTCOME
1. Indicate the extent of remediation covered by the Response Action Outcome.
Check only 1 box:
Unrestricted RAO
Limited Restricted RAO
Restricted RAO
2. Check only 1 box:
Area(s) of Concern Only
Entire Site
ISRA Subject Industrial Establishment (leasehold portion only)
3. Total number of contaminated AOCs associated with the case:
4. Total number of contaminated AOCs addressed in this submission:
5. Are there any outstanding contaminated AOCs associated with the case where an RAO
has not been filed? .......................................................................................................................................
Yes
No
6. Does this RAO address a discharge/release from a federally regulated UST? ...........................................
Yes
No
SECTION C. RESPONSE ACTION OUTCOME PREPARATION CHECKS
1. Was the RAO issued only to the “Person(s) that conducted the Remediation”? ........................................
Yes
No
2. Does the language in the issued RAO document conform to the RAO shell document? ...........................
Yes
No
3. Were all the applicable individuals/agencies noted in the shell document copied on the RAO? ................
Yes
No
4. Are there electronic copies of all remediation related records included with this submission? ...................
Yes
No
5. Did the remedial action render the property unusable for future redevelopment or recreation use? ..........
Yes
No
6. Have any NJDEP-documented deficiencies been addressed in this or prior submission? ..........
Yes
No
N/A
SECTION D. RESPONSE ACTION OUTCOME NOTICES (check all the apply and were used in the RAO document)
1. General Notices
Well Decommissioning
Building Interiors Not Addressed (Non-Child Care)
Building Interiors Addressed
Response Action Outcome
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Version 3.3 05/27/15
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