MUNICIPAL SOLID WASTE LANDFILL CLOSURE PLAN (329 IAC 10-22) State Form 50391 (R / 7-06) Indiana Department of Environmental Management INSTRUCTIONS INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Office of Land Quality Solid Waste Permits Section - Mail Code 65-45 100 N. Senate Ave. Indianapolis, IN 46204-2251 This application form shall be used to submit closure plans for municipal solid waste landfills (MSWLFs) both individually and with permit applications. When completed, closure plans should be submitted, either individually or with permit applications, along with support documentation, to the address given in the box above. I. General Information Facility Name Facility Location Facility County Facility Solid Waste Permit No. (if existing permitted facility) Total Fill Acreage II. Closure Activities-General Description Provide a description of the steps that will be used to partially close, if applicable, and finally close the facility. See instructions for items that should be included Page 1 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com II. Closure Activities-General Description (continued-copy additional pages as needed) Page 2 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com III. Final Cover Description Provide a detailed description of the final cover (see instructions). Attach additional sheets as necessary. Page 3 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com IV. Labor, Materials, and Testing Provide a listing of items necessary to close the facility (see instructions). For items that will vary depending upon the number of acres to be closed, the quantities should be indicated on a per acre basis. Include items for both the closure activities and final cover noted above. Use additional sheets as needed. A. Item Page 4 of 21 B. Quantity (use applicable unit as appropriate C. Units (use unit as appropriate) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com V. Expected Year of Closure and Closure Schedule Please see instructions; attach additional sheets as necessary. A. Expected Year of Closure B. Total Time Required to Close Facility C. Time Required for Completion of Intervening Closure Activities Provide a description of intervening closure activities and the time required; see instructions. Page 5 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com VI. Estimate of Maximum Inventory of Waste Page 6 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com VII. Estimate of Cost Per Acre for Final Cover & Vegetation Please see instructions; attach additional sheets as necessary. A. Cover Material Availability, & Acquisition, Placement And Compaction Costs For Areas Closing With A Composite Bottom Liner And A Leachate Collection System-329 IAC 10-22-6(b)) 1. Percent of Final Cover Material Available from Areas That Are Controlled, and Will be Controlled Through Post-Closure, by the Owner, Operator, or Permittee. a. Methane gas venting layer material (12 inches) or landfill gas (LFG) extraction well material 1) 2) b. % of material Describe location of sources (include distance from facility) Soil barrier layer material (lower 12 inches-structural fill) 1) 2) c. % of material Describe location of sources (include distance from facility) Soil barrier layer material (upper 12 inches-structural fill) 1) % of material 2) Describe location of sources (include distance from facility) d. Geomembrane layer – not applicable-delivered to site e. Drainage layer material 1) 2) f. % of material Describe location of sources (include distance from facility) Top protective soil layer material (18 inches; 30 inches if geosynthetic drainage layer used) 1) 2) g. % of material Describe location of sources (include distance from facility) Vegetative Layer (topsoil) (6 inches) 1) 2) 2. % of material Describe location of sources (include distance from facility) Cost Per Acre for Acquisition, Placement & Compaction of Final Cover Layers a. Methane gas venting layer material (12 inches) or LFG Extraction System 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and spreading a) Placement/spreading cost ($/yd3) b) Page 7 of 21 1,613 yd3 Placement and spreading costs ($/acre) line 1.a * line 2.a Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com 3) Installation of gas well system a) b) Number of units to be installed c) 4) Installation unit cost ($/unit) Total cost of installation Line 3.a * line 3.b Testing and QA/QC a) b) b. Survey cost ($/acre) c) 5) Lab testing per QA/QC plan ($/acre) Testing/CQA cost ($/acre) Line 4.a * line 4.b Total Cost, Methane Gas Venting Layer ($/Acre) OR LFG System Line 1.e + line 2.b + line 3c +line 4c Soil Barrier Layer Material and Structural Fill (24 inches) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and compaction a) Placement/spreading cost ($/yd3) b) Compaction unit cost ($/yd ) c) 3) Placement and compaction costs ($/acre) Line 1.a * (line 2.a + line 2.b) 3 Testing and QA/QC a) Survey control for cover thickness ($/acre) c) Density and moisture content testing (if planned) ($/acre) d) c. Tests for grain size, Atterberg limits and hydraulic conductivity ($/acre) b) 4) Testing cost ($/acre) Line 3.a + line 3.b + line 3.c Total Cost, Soil Barrier Layer and Structural Fill ($/Acre) Line 1.e + line 2.c + line 3.d Geomembrane Liner 1) Acquisition a) Quantity of material needed per acre (yd2) b) Purchase unit cost ($/yd2) c) Delivery unit cost ($/yd2) (if applicable) d) Page 8 of 21 3,227 yd3 4,840 yd2 Acquisition cost ($/acre) Line 1.a * (line 1.b + line 1.c) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com 2) Placement a) b) 3) Placement cost ($/yd2) (if applicable and not included in purchasing unit cost) Placement ($/acre) Line 1.a * line 2.a Testing and QA/QC a) b) d. Other testing ($/acre) c) 4) Fingerprinting, destructive (shear,and peel tests) & non-destructive seam test) ($/acre) Testing cost ($/acre) Line 3.a + line 3.b (if applicable) Total Cost, Geomembrane Liner ($/Acre) Line 1.d + line 2.b + line 3.c Drainage Layer Material (12 inches) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and spreading a) Placement/spreading cost ($/yd3) b) 3) Placement and spreading costs ($/acre) Line 1.a * line 2.a Testing and QA/QC a) Survey control for cover thickness ($/acre) c) e. Tests for grain size and hydraulic conductivity ($/acre) b) 4) Testing cost ($/acre) Line 3.a + line 3.b Total Cost, Drainage Layer Material ($/Acre) Line 1.e + line 2.b + line 3.c Top Protective Soil Layer Material Per Acre (18 inches; 30 inches if geosynthetic drainage layer used) If drainage layer constructed of soil, the top protective soil layer must be at least 18 inches thick (2420 yd3/ac); if drainage layer constructed with geosynthetics, the top protective soil layer must be at least 30 inches thick (4033 yd3/ac). 1) Acquisition a) Quantity of material needed per acre (yd3) b) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2,420 yd3-18 in. layer 4,033 yd3-30 in. layer Excavation unit cost ($/yd3) (if obtained on-site) c) Page 9 of 21 1,613 yd3 Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com 2) Placement and spreading a) b) 3) Placement/spreading cost ($/yd3) Placement and spreading costs ($/acre) Line 1.a * line 2.a Testing and QA/QC a) b) f. Survey control for cover thickness ($/acre) c) 4) Tests for grain size ($/acre) Testing cost ($/acre) Line 3.a + line 3.b Total Cost, Top Protective Soil Layer ($/Acre) Line 1.e + line 2.b + line 3.c Vegetative Layer (topsoil) Material (6 inches) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement a) g. B. Spreading unit cost ($/yd3) b) 3) 807 yd3 Placement costs ($/acre) Line 1.a * line 2.a Total Cost, Vegetative Soil Layer ($/acre) Line 1.e + line 2.b Total Cost Per Acre For Acquisition, Placement & Compaction Of Final Cover Layers Line a.4 + line b.4 + line c.4 + line d.4 + line e.4 + line f..3 Availability, & Acquisition, Placement And Compaction Costs For Areas Closing With A Soil Bottom Liner And A Leachate Collection System With Slopes Equal To Or Less Than 15%-329 Iac 10-22-7(b)(1) 1. Percent of Final Cover Material Available from Areas That Are Controlled, and Will be Controlled Through Post-Closure, by the Owner, Operator, or Permittee. a. 7 Soil Barrier Layer Material (24 inches; k ≤1 x 10- cm/sec) 1) 2) b. % of material Describe location of sources (include distance from facility) Vegetative Layer (lower 12 inches-structural fill) 1) 2) 2. % of material Describe location of sources (include distance from facility) Cost Per Acre for Acquisition, Placement & Compaction of Final Cover Layers a. -7 Soil Barrier Layer Material (24 inches; k ≤ 1 x 10 cm/sec) 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Page 10 of 21 Quantity of material needed per acre (yd3) 3,227 yd3 Purchase unit cost ($/yd3) (if obtained off-site) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com d) e) 2) Delivery unit cost ($/yd3) (if obtained off-site) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and compaction a) b) Compaction unit cost ($/yd3) c) 3) Placement/spreading cost ($/yd3) Placement/spreading and compaction costs ($/acre) line 1.a * ( line 2.a + line 2.b) Testing and QA/QC a) b) Density testing ($/acre) d) b. Survey control for cover thickness ($/acre) c) 4) Tests for grain size, Atterberg limits and hydraulic conductivity ($/acre) Testing/CQA cost ($/acre) Line 3.a + line 3.b + line 3.c Total Cost, Soil Barrier Layer ($/acre) Line 1.e + line 2.c + line 3.d Vegetative Layer (topsoil) Material (6 inches) 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement a) g. C. Spreading unit cost ($/yd3) b) 3) 807 yd3 Placement costs ($/acre) Line 1.a * line 2.a Total Cost, Vegetative Soil Layer ($/acre) Line 1.e + line 2.b Total Cost Per Acre For Acquisition, Placement & Compaction Of Final Cover Layers Line a.4 + line b.3 Availability, & Acquisition, Placement And Compaction Costs For Areas Closing With A Soil Bottom Liner And A Leachate Collection System With Slopes Greater Than 15%-329 IAC 10-22-7(b)(2) 1. Percent of Final Cover Material Available from Areas That Are Controlled, and Will be Controlled Through Post-Closure, by the Owner, Operator, or Permittee. a. Soil Barrier Layer Material (24 inches; thickness may be more per approved plan; k ≤1 x 106 cm/sec) 1) 2) b. % of material Describe location of sources (include distance from facility) Vegetative Layer 1) 2) Page 11 of 21 % of material Describe location of sources (include distance from facility) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com 2. Cost Per Acre for Acquisition, Placement & Compaction of Final Cover Layers a. -7 Soil Barrier Layer Material (24 inches; k ≤1 x 10 cm/sec) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and compaction a) Placement/spreading cost ($/yd3) b) Compaction unit cost ($/yd3) c) 3) Placement and compaction costs ($/acre) line 1.a * (line 2.a + line 2.b) Testing and QA/QC a) Survey control for cover thickness ($/acre) c) Density testing ($/acre) d) b. Tests for grain size, Atterberg limits and hydraulic conductivity ($/acre) b) 4) Testing cost ($/acre) Line 3.a + line 3.b + line 3.c Total Cost, Soil Barrier Layer ($/acre) Line 1.e + line 2.c + line 3.d Vegetative Layer (topsoil) Material (6 inches) Per Acre 1) Acquisition a) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) b) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Page 12 of 21 Spreading unit cost ($/yd3) b) 3) 807 yd3 Placement a) c. 3,227 yd3 Placement costs ($/acre) Line 1.a * line 2.a Total Cost, Vegetative Layer (topsoil) ($/acre) Line 1.e + line 2.b Total Cost Per Acre For Acquisition, Placement & Compaction Of Final Cover Layers Line a.4 + line b.3 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com D. Availability, & Acquisition, Placement And Compaction Costs For Areas Closing Without A Composite Or Soil Bottom Liner Or A Leachate Collection System, Closing After January 1, 1998, With Slopes Equal To Or Less Than 15%-329 IAC 10-22-7(c)(1) 1. Percent of Final Cover Material Available from Areas That Are Controlled, and Will be Controlled Through Post-Closure, by the Owner, Operator, or Permittee. a. Methane gas venting layer material (12 inches) or landfill gas (LFG) extraction well material 1) 2) b. % of material Describe location of sources (include distance from facility) Soil barrier layer material (lower 12 inches-structural fill) 1) 2) c. % of material Describe location of sources (include distance from facility) Soil barrier layer material (upper 12 inches) 1) % of material 2) Describe location of sources (include distance from facility) d. Geomembrane layer – not applicable-delivered to site e. Drainage layer material (12 inches) 1) 2) f. % of material Describe location of sources (include distance from facility) Top protective soil layer material (18 inches; 30 inches if geosynthetic drainage layer used) 1) 2) g. % of material Describe location of sources (include distance from facility) Vegetative Layer (topsoil) (6 inches) 1) 2) 2. % of material Describe location of sources (include distance from facility) Cost Per Acre for Acquisition, Placement & Compaction of Final Cover Layers a. Methane gas venting layer material (12 inches) or LFG Extraction System 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and spreading a) Placement/spreading cost ($/yd3) b) 3) Placement and spreading costs ($/acre) line 1.a * line 2.a Installation of gas well system a) Page 13 of 21 1,613 yd3 Installation unit cost ($/unit) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com b) c) 4) Number of units to be installed Total cost of installation Line 3.a * line 3.b Testing and QA/QC a) b) b. Survey cost ($/acre) c) 5) Lab testing per QA/QC plan ($/acre) Testing/CQA cost ($/acre) Line 4.a + line 4.b Total Cost, Methane Gas Venting Layer ($/Acre) OR LFG System Line 1.e + line 2.b + line 3c +line 4c Soil Barrier Layer Material and Structural Fill (24 inches) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and compaction a) Placement/spreading cost ($/yd3) b) Compaction unit cost ($/yd ) c) 3) Placement and compaction costs ($/acre) Line 1.a * (line 2.a + line 2.b) 3 Testing and QA/QC a) Survey control for cover thickness ($/acre) c) Density and moisture content testing ($/acre) d) c. Tests for grain size, Atterberg limits and hydraulic conductivity ($/acre) b) 4) Testing cost ($/acre) Line 3.a + line 3.b + line 3.c Total Cost, Soil Barrier Layer and Structural Fill ($/Acre) Line 1.e + line 2.c + line 3.d Geomembrane Liner 1) Acquisition a) Purchase unit cost ($/yd2) c) Delivery unit cost ($/yd2) (if applicable) d) 2) Quantity of material needed per acre (yd2) b) Acquisition cost ($/acre) Line 1.a * (line 1.b + line 1.c) Placement cost ($/yd2) (if applicable and not included in purchasing unit cost) b) 3) 4,840 yd2 Placement a) Placement ($/acre) Line 1.a * line 2.a Testing and QA/QC a) Page 14 of 21 3,227 yd3 Fingerprinting, destructive (shear,and peel tests) & non-destructive seam test) ($/acre) Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com b) c) 4) d. Other testing ($/acre) Testing cost ($/acre) Line 3.a + line 3.b (if applicable) Total Cost, Geomembrane Liner ($/Acre) Line 1.d + line 2.b + line 3.c Drainage Layer Material (12 inches) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and spreading a) Placement/spreading cost ($/yd3) b) 3) Placement and spreading costs ($/acre) Line 1.a * line 2.a Testing and QA/QC a) Survey control for cover thickness ($/acre) c) e. Tests for grain size and hydraulic conductivity ($/acre) b) 4) Testing cost ($/acre) Line 3.a + line 3.b Total Cost, Drainage Layer Material ($/Acre) Line 1.e + line 2.b + line 3.c Top Protective Soil Layer Material (18 inches; 30 inches if geosynthetic drainage layer used) If drainage layer constructed of soil, the top protective soil layer must be at least 18 inches thick (2420 yd3/ac); if drainage layer constructed with geosynthetics, the top protective soil layer must be at least 30 inches thick (4033 yd3/ac). 1) Acquisition a) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and spreading a) Placement/spreading cost ($/yd3) b) 3) 2,420 yd3-18 in. layer 4,033 yd3-30 in. layer Excavation unit cost ($/yd3) (if obtained on-site) c) 2) Quantity of material needed per acre (yd3) b) Placement and spreading costs ($/acre) Line 1.a * line 2.a Testing and QA/QC a) Tests for grain size ($/acre) b) Survey control for cover thickness ($/acre) c) Page 15 of 21 1,613 yd3 Testing cost ($/acre) Line 3.a + line 3.b Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com 4) f. Total Cost, Top Protective Soil Layer ($/Acre) Line 1.e + line 2.b + line 3.c Vegetative Layer (topsoil) Material (6 inches) 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement a) g. E. Spreading unit cost ($/yd3) b) 3) 807 yd3 Placement costs ($/acre) Line 1.a * line 2.a Total Cost, Vegetative Layer ($/acre) Line 1.e + line 2.b Total Cost Per Acre For Acquisition, Placement & Compaction Of Final Cover Layers Line a.4 + line b.4 + line c.4 + line d.4 + line e.4 + line f.3 Availability, & Acquisition, Placement And Compaction Costs For Areas Closing Without A Composite Or Soil Bottom Liner Or A Leachate Collection System, Closing After January 1, 1998, With Slopes Greater Than 15%-329 IAC 10-22-7(c)(2) 1. Percent of Final Cover Material Available from Areas That Are Controlled, and Will be Controlled Through Post-Closure, by the Owner, Operator, or Permittee. a. Soil barrier layer material (24 inches-thickness may be more per approved plan; k ≤1 x 10-6 cm/sec) 1) 2) b. % of material Describe location of sources (include distance from facility) Vegetative Layer (topsoil) 1) 2) 2. % of material Describe location of sources (include distance from facility) Cost Per Acre for Acquisition, Placement & Compaction of Final Cover Layers a. -6 Soil Barrier Layer Material (24 inches) Per Acre, k≤1X10 cm/sec 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement and compaction a) Placement/spreading cost ($/yd3) b) Compaction unit cost ($/yd ) c) Page 16 of 21 3,227 yd3 Placement and compaction costs ($/acre) Line 1.a * (line 2.a + line 2.b) 3 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com 3) Testing and QA/QC a) b) Density testing ($/acre) d) b. Survey control for cover thickness ($/acre) c) 4) Tests for grain size, Atterberg limits and hydraulic conductivity ($/acre) Testing cost ($/acre) Line 3.a + line 3.b + line 3.c Total Cost, Soil Barrier Layer ($/Acre) Line 1.e + line 2.c + line 3.d Vegetative Layer (topsoil) Material (6 inches) Per Acre 1) Acquisition a) b) Excavation unit cost ($/yd3) (if obtained on-site) c) Purchase unit cost ($/yd3) (if obtained off-site) d) Delivery unit cost ($/yd3) (if obtained off-site) e) 2) Quantity of material needed per acre (yd3) Acquisition cost ($/acre) Line 1.a * line 1.b (on-site) or Line 1.a * (line 1.c + line 1.d) (off-site) Placement a) 3) F. Spreading unit cost ($/yd3) b) c. Placement costs ($/acre) Line 1.a * line 2.a Total Cost, Vegetative Layer ($/acre) Topsoil Line 1.e + line 2.b Total Cost Per Acre For Acquisition, Placement & Compaction Of Final Cover Layers Line a.4 + line b.3 Cost per Acre to Establish Vegetation (all areas) 1. Vegetation a. Seeding unit cost ($/acre) b. Fertilization unit cost ($/acre) c. Mulching unit cost ($/acre) d. G. 807 yd3 Total Vegetation Establishment Costs ($/acre) Line 1.a + line 1.b + line 1.c Cost per Acre to Certify Closure (all areas) 1. Registered Professional Engineer (PE) a. Initial review of closure plan (hrs) b. Total number of inspections c. Inspection time required (hrs/visit) d. Total inspection time (hrs) Line 1.b * line 1.c e. Prepare final documentation of construction of cover (hrs) f. Total engineer time (hrs) Line 1.a + line 1.d + line 1.e g. Professional engineer labor cost ($) h. Professional engineer cost ($) Line 1.f * line 1.g Page 17 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com i. j. H. Area of site permitted for filling (acres) Total Closure Certification Costs ($/acre) Line 1.h ÷ line 1.i Other Costs Per Acre For Final Cover And Certification (All Areas) – describe below ($/acre) Activity Cost Total, Other Costs Per Acre ($/acre) I. SUBTOTAL, PER ACRE FINAL COVER AND CERTIFICATION COSTS For closure over areas with composite bottom liner system, enter amount no less than $78,750 For closure over areas without composite bottom liner system, enter amount no less than $21,000 Note: for an application for a new MSWLF or major modification submitted on or after April 1, 2005, the minimum closure costs per acre must be adjusted for inflation as described in 329 IAC 10-39-2(c)(1). (Total, Section A.2 + Total, Section B.2, + Total, Section C.2 + Total, Section D.2 + Total, Section E.2 + Total, Section F + Total, Section G + Total, Section H) * (inflation adjustment factor) VIII. Other Closure Costs Please give on a total facility basis rather than a per acre basis A. Notation of Property Deed B. Other Costs – include here costs for such items as drainage features, gas vents, etc. Activity Cost Total, Other Costs C. TOTAL, OTHER CLOSURE COSTS Line A + line B IX. Total Closure Cost Total fill acreage * item VII.I (per acre final cover and certification costs)] + item VIII.C (other closure costs) X. Contingency Cost Line IX * (0.10) XI. Total Closure Cost Estimate (including contingency cost) Line IX + line X XII. Final Closure Cost Per Acre Line XI ÷ total fill acreage Page 18 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com XIII. Construction Quality Assurance/Quality Control Plan Attach at the end of this closure plan form a construction quality assurance/quality control plan detailing the quality assurance/quality control steps that will be taken during construction and installation of the final cover system. Construction quality assurance/quality control plan attached? XIV. Optional - Information Required For Facilities Incrementally Funding Financial Assurance Enter "na" on the first line of the table if you are not incrementally funding using one of these options A. Maximum Areas of Waste Deposition and Closure Costs – provide in the table below the listed information for each remaining year of the facility’s life Year Maximum Area of Waste Deposition (cumulative acres at end of each year Closure Cost w/o Partial Closure ($) Area Partially Closed (cumulative acres at start of each year) Incremental Closure Cost Estimate ($) Attach additional sheets if your facility's expected remaining lifetime is more than 20 years B. Map of Areas of Waste Deposition - Attach copy of facility's final contour map marked to show the maximum areas of waste deposition for each succeeding year of the remaining life of the facility. Page 19 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com XV. Largest Closed Area Estimate Provide an estimate of the largest area of the MSWLF unit ever requiring a final cover at any time during the unit’s proposed active life. Page 20 of 21 Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com XVI. Optional - Estimate Of Yearly Maintenance Costs For A Dike Or Dikes Required For Construction In Flood Plain Provide in the table below estimates for the yearly maintenance costs for any dikes you will build if you are constructing your facility in a flood plain. Enter "na" on the first line if not applicable. Year Costs ($) Year Costs ($) Attach additional sheets if your facility’s expected remaining lifetime is more than 20 years. XVII. Signatory Certification 329 IAC 11-9-3(d) requires that the signatory for a permit application sign the following certification statement: “I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I further certify that I am authorized to submit this information.” Applicant’s Name & Title Typed Applicant’s Typed Address Page 21 of 21 Applicant’s Signature Street Date Signed P.O. Box Town/City Although this form is being provided to aid you in preparing your closure plan in accordance with the solid waste rules, this form is subject to review and revision. Please consult the actual rule language. American LegalNet, Inc. www.FormsWorkflow.com