Quality Control Plan for Environmental Monitoring Form

I. Project Information

Project Name

Contract ID

State/Federal Project Number

Bridge Number

District

County

II. Contractor Information

Contractor Name

Contractor Phone Number

Contractor Address

Contractor Contact Person

Official Responsible for Quality Control

Liaison with Division of Highways Personnel

III. Abrasives/Additives

Trade Name of Abrasive

Recyclable?

Yes

Manufacturer of Abrasive

Size of Abrasive

Abrasive Additive (if Any)

Trade Name of Additive (if Any)

Manufacturer of Additive (if Any)

IV. Environmental Controls

Environmental Containment as Per Plans

Environmental Monitoring Methods as Per Plans

V. Hazardous Waste/Non Hazardous Waste Disposal

Hazardous Waste Disposal Company

Contact Person for Hazardous Waste Disposal Company

Address of Hazardous Waste Disposal Company

Hazardous Waste Transporter Company

Contact Person for Hazardous Waste Transporter Company

Address of Hazardous Waste Transporter Company

Hazardous Waste Disposal Site

Non-Hazardous Waste Material Company

Contact Person for Non-Hazardous Waste

Address of Non-Hazardous Waste Material Company

Upon completion of this form, please submit to the West Virginia Division of Highways, Materials Control, Soils and Testing using the submit button below. An email will be generated with the plan attached and the address populated for sending. Please attach any supporting documentation at that time.

Person Completing Form

Contact Phone Number

Contact Email Address