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HomeMy WebLinkAbout151 Sand Hill Road (6) Electric# 17 1 APPLICATION FOR BUILDING PERMIT Plumbing# 151 Sand Hill Road HVAC # Date: 3 - 3 - Z Sprinkler# No. 2 8.6 0 7 FINAL APPROVALS Estimated Cost $ o t<j Building COMPLETE RED BOXED AREAS Permit Fee $ (2S� Engineering TYPE OR PRINT ONLY Occupancy Fee $ Affidavit _ J SIGN ON REVERSE SIDE` Appr.for.CO. a -8 3 _ Total Fee $ TO BUILDING DEPARTMENT,TOWN OF SOUTH WINDSOR,CT (Additional Cost) $ The undersigned hereby applies to do work according to the followingspecifications: Job Location j S SA^J D AtL ? 4W b Lot No. Side of Street S w7W Zone A44,,6S Applicant s'��7''/"Jo��a�tx Z41 R4 .SS E c-yi�'F Tel.# S"1 3 - 74, 3 e. Address -1"0 D z::,a T�aPY�! SE l7iL .3,td R• tliu Zip O D Lic.# / Owner 5dA 7-s w ck s Address �D o-9 S-re,& ,6,-✓D � /1.L/9 S i O A'40d?Y Olo 0 3 Architect Address Sq.Ft.New Area: 1st FL 2nd A. 3rd FL Total New Area #Rooms #Lavatories_ #Bathrooms #Garages Purpose of this permit: Cez-4- S,T�- �.✓ S i f9 �.L '�'�a^/ ©f 6l d� F^-'i City Water ❑ Well ❑ Septic System ❑ Sewer ❑ Ins. H.O. S.P. Cert. � Area Basement Garage Approved by Date t 310 Use Group U Construction Type 2C_ Revised 9/01 I hereby agree to conform to all the requirements of the Laws of the State of Connecticut and the Ordinances of the Town of South Windsor and to notify the Building Inspector of any alteration in the plans or specifications of the Building for which this permit is asked,and agree that this building is to be locat the proper distance from all street lines,side yard lines,and required distances from all other zones and is located in whichuse is allowed. V Signed -- I hereby apply for a Certificate of Occupancy f the rk its application for the permit. Signed DO NOT WRITE BELOW THIS LINE INSPECTION COMMENTS Eastern A Division of - Materials Testing Laboratory Eastern Materials Testing Laboratory a division of ' 0 �WLAP#10 JAWORSKI GEOTECH, INC. JAWORSKI CONCRETE DATA SUMMARY GEOTECH, INC. Project: Nextel Tower Project No. : 02452C Windsor, CT Contractor: Construction Services Client: Construction Services SubContractor: Lauretti Construction Supplier: Tilcon JGI Representative: S. Anglin PLACEMENT DATA Placement Date: 7/25/02 Cylinder Set No. : C1 Time: 11:10 Truck No. : 125 Class Concrete: 3,500 psi 3/411 Ticket No. : 808041 Total Quantity 5 cy Batch Time: 10:22 Batch Quantity: 5 cy Air: Specified: 4-6% Method of Placement: chute Measured: 6.25 Location of Sample: southeast pier Slump Specified: 5" max. Measured: 4,25" Total Location of Placement: piers at equipment shelter Unit Weight: 145.08 lbs/cu./ft. Plastic Wt. : Cylinder Wt. : X Concrete Temperature: 80 degrees F Cylinder Size: 6 x 12 inches Ambient Temp: 74 degrees Date Retrieved: 7/29/02 End Area: 28.27 sq in Method of Compression: Neoprene Caps BATCH TICKET INFORMATION(reduced to 1 cubic yard) Cem Types of Fracture l lbs./cu./yd Sand: not provided lbs./cu./yd b d e Cem2 lbs./cu./yd Water: lbs./cu./yd Cem 3 lbs./cu./yd Adl oz/cu./yd \ l l l Agg 1 lbs./cu./yd Ad2 oz/cu./yd �� A Agg 2 lbs./cu./yd Ad3 oz/cu./yd Agg 3 lbs./cu./yd AN oz/100 CWT` Cope Cone&rW Cone and Shear Columnar Sand Moisture: Stone Moisture: SjA't Shear COMPRESSIVE STRENGTH DATA Cylinder ID C 1 A C 1 B C 1 C C 1 D C 1 E _ Date Cast 7/25/02 7/25/02 7/25/02 7/25/02 7/25/02 Date Tested 7/28/02 8/1/02 8/22/02 8/22/02 9/19/02 Specimen Age ( 3 days) ( 7 days) ( 28 days) (28 days) (56 days) Cyl.Weight (lbs. ) 28.48 28.62 28.58 28.40 28.34 Load (lbs. ) 88,297 95,614 Stress (psi) 3,120 3,380 Type of Fracture a Reviewed by: �yrG Date: The information stated on this report may not be reproduced except in its entirety without the express written consent of Eastern Materials Testing a division of Jaworski Geotech,Inc. Use of the NVLAP designation does not represent endorsement by the NIST or NVLAP.Reports are relevant only to items tested,and no other attribution may be made. Sampling and testing were performed in general accordance with the following ASTM standards: C 39,C 31,C 94,C 143,C 172,C 192,C 231,C G7,and C 1231. Electric# APPLICATION FOR BUILDING PERMIT Plumbing# 15I Sand Hill Road HVAC # Date: ZOOS Sprinkler# FINAL R Estimated Cost Building o Permit Fee Engine n COMPLETE RED BOXED AREAS TYPE OR PRINT ONLY Occupancy Fee $ Affidavit Eng.Insp.Fee $ Appr.for CO. ► SIGN ON REVERSE SIDE 4] Total Fee $TO THE BUILDING DEPARTMENT,TOWN OF SOUTH WINDSOR,CT (Additional Cost) $ The undersigned hereby applies to do work according to the following: Applicant WEyl 17 ll`1 (2a®FIAIG (fo Location of Work_ t _ Mb FBI LL IZ) (5w��ot No. Applicant's Address i 35 y St 2Ft=T Tel.# Town EWING'iaN , C'r Zip Ofo)i ( Lic.# 911'0037 Sf Owner Architect �A P- a►.,A CO. Owner's Address-TD( KI of SDuT H tdj 11r: Architect's Address_LOoEpp- _nc� fto,gp 15�10 SvIlwA,v AUE. S•(,l)•, GT Zip WEtNERSE—LO C7 Zip Qk� Sq. Ft. New Area: 1 st FI. 2nd FI. 3rd Ff. Total New Area Purpose oi'this permit E- RooF SA) P ) City Water❑ Well❑ Septic System❑ Sewer❑ As:ra d b SP Cert. Area Basement g Approved y Date 2, �- Gara e /� 4� Use Groff—' Construction Type Revised 6/02 I hereby agree to conform to all the requirements of the Laws of the State of Connecticut and the Ordinances of the Town of South Windsor and to notify the Building Inspector of any alteration in the plans or specifications of the Building for which this permit is asked,and agree that this building is to be located the proper distance from all street lines,side yard lines,and required distances from all other zones and is located in which this ng and' is alkrwed. Signe I hereby apply for a Certificate of Occupancy for the work described in this application for the permit. Signed DO NOT WRITE BELOW THIS LINE INSPECTION COMMENTS DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT TOWN OF SOUTH WINDSOR PERMIT# Applicatio BUILDING DEPARTMENT �l �'P 1540 SULLIVAN AVENUE Bldg.Permit# J 644-2511 ext.230 Date Buildin nspector Application must be printed or typed FEE SCHEDULE Location of Job: $0-$1,000=$15.00 Street No. Street Lot No. Over$1,000= $15.00 per$1,000 or any fraction thereof Tenant Designation Apt.No. APPLICANT APPLICANT ADDRESS L4 C 6,IR APPLICANT PHONE# OWNER �6wn 6T Sov ���dS� L �pW N SFq -- - OWNER ADDRESS OWNER PHONE ,s C ESTIMATED COST$ 5-dZqo, "o IS THIS A CONTRACT COST? ✓Yes No �CJ FEE ENCLOSED$ . wtl r U r �s O��` TYPE OF JOB: 0R-C New Installation �Alteration/Addition/Repair Revised 4/01//2002 APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side) TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A ❑RESIDENTIAL BUILDING PERMIT APPLICATION? ElYES tj NO 0 BUSINESS CENT USE AND OCCUPANCY ❑ASSEMBLY ❑MERCANTILE❑EDUCATIONAL FUTURE USE AND OCCUPANCY ❑INSTITUTIONAL ❑FACTORY ENGINEER'S NAME PHONE ❑STORAGE ❑GARAGE ADDRESS ❑MIXED USE P,�'C,- S�1Q^ CITY STATE ZIP (Other please specify) TYPE OF INSTALLATION/WIRING METHOD Wt fZkA5_of' iCeG SIZE OF SERVICE SIZE OF MAIN CONDUCTORS NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS NUMBER OF PANELS REMOTE DISCONNECT REQUIRED? ❑YES ❑NO NUMBER OF LIGHT CIRCUITS NUMBER OF POWER CIRCUITS NUMBER OF SWITCHES NUMBER OF OUTLETS NUMBER OF LIGHT FIXTURES NUMBER OF HEAT CIRCUITS NUMBER OF A/C CIRCUITS SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED. DESCRIPTION OF F WORK Q J 1 Ce J 7 THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE PERFORMANCE OF SUCH WORK. 16-/ S k 7 �� �' r CONTRACTORS LICENSE NO. TYPE STATE SIGNATURE OF APPLICANT DATE / C; DEPARTMENT DECISION APPLICATION FOR PLUMBING PERMIT Ap TOWN OF SOUTH WINDSOR PERMIT' i S ITfl BUILDING DEPARTMENT APPRo 1540 SULLIVAN AVENUE Bldg.Permit# 1 644-2511 ext. 230 Oki Date Building infector Application must be printed or typed FEE SCHEDULE Location of Job: i s/ 5 )lic4 ,9 $0-$1,000=$15.00 Street No. Street Lot No. Over$1,000= $15.00 per$1,000 or any fraction thereof Tenant Designation Apt.No. APPLICANT (J1�1,90xJC CKJ APPLICANT ADDRESS 9?3ZL7S4Qooj �) APPLICANT PHONE# S O W N St-4 OWNER ?bm i n z OWNER ADDRESS 1J i L&� 19 OWNER PHONE C ESTIMATED COST$ � IS THIS A CONTRACT COST? _Yes _No } G FEE ENCLOSED$ -tt-)A i d l�,ljS TYPE OF JOB: OR•CO�.� _New Installation Alteratio Additio epair Revised 4/01//2002 APPLICATION FOR PLUMBING PERMIT (Continued from reverse side) TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A El RESIDENTIAL BUILDING PERMIT APPLICATION? ❑YES J�26NO 0 BUSINESS CURRENT USE AND OCCUPANCY ❑ASSEMBLY ❑MERCANTILE FUTURE USE AND OCCUPANCY ❑EDUCATIONAL INSTITUTIONAL ❑FACTORY ENGINEER'S NAME PHONE ❑STORAGE ❑GARAGE ADDRESS ❑MIXED USE CITY STATE ZIP (Other please specify) TYPE OF INSTALLATION eito b d7- PLjt-�P SIZE OF MAIN DRAIN NO.OF TOILETS STYLE NO.URINALS STYLE NO.OF BATHTUBS NO.OF SHOWERS NO.OF LAVATORIES NO.OF CONDUCTORS SIZE NO.OF STACKS SIZE AREA OF ROOF NO.OF CATCH BASINS NO.OF FLOOR DRAINS NO.OF OTHER FIXTURES KIND ARE TOILET COMPARTMENTS VENTILATED TO OUTER AIR BY A WINDOW ❑YES ❑NO SIZE OF WINDOW IF NONE C.F.M.OF VENTILATOR SIZE OF DUCTS SEWER OR SEPTIC TANK SIZE OF WATER MAIN SIZE OF WATER PIPING&RISER WATER HEATER: TYPE MANUFACTURER DESCRIPTION OF WORK THE UNDERSIGNED HERE13Y APPLIES FOR A PMM17-O PERFORM 1HE WORK DESCR I ED AND ITTn— COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE PERFORMANCE OF SUCH WORK. 9_779 p 9 C7_ CONTRACTORS LICENSE NO. TYPE STATE SIGNATURE OF APPLICANT DATE / �0� Electric# APPLICATION FOR BUILDING PERMIT Plumbing# 151 Sand Hill Road Date: 4 HVAC # Sprinkler# 30457 Estimated Cost N► 3 ®� FINAL APPROVALS Permit Fee $ Building COMPLETE RED BOXED AREAS Engineering TYPE OR PRINT ONLY Occupancy Fee $ l Affidavit Eng. Insp.Fee $ Appr. for CO SIGN ON REVERSE SIDE / Total Fee $ 06- 3-d TO THE BUILDING DEPARTMENT,TOWN OF SOUTH WINDSOR, CT (Additional Cost) $ The undersigned hereby applies to do work according to the following: Applicant S 'location of Work Lot No. .vi, i\a Applicant's Address Town Zip C'�oO0 -Lic.# S _ MCjQ.2jnin2Q Owner_'-,P, ✓o .jo, 'T-zG. Architect z Owner's Address Architect's Address Zip G-r Zip ' Sq. Ft. New Area: 1 st FI. 2nd Fl. 3rd A. �— Total New Area Purpose of this Dermit ' City Water❑ 'Well❑ Septic System❑ Sewer❑ i Ins: HO Area Basement Garage Approved by Date'_'` Kam , Use Group Construction Type �— Revised 6/02 I hereby agree to conform to all the requirements of the Laws of the State of Connecticut and the Ordinances of 6h Town of South Windsor and to notify the Building Inspector of any afteratlon in the plans or specifications of the Building for which this permit is asked,and agree that this building is to be located the proper distance from all street lines,side yard lines,and required distances from all other zones and is located' is building and its use is allowed. Signed I hereby apply for a Certificate of u y for the work described in this application for the permit. -� Signed DO NOT WRITE BELOW THIS LINE INSPECTION COMMENTS Inspection / Approval Date By Appl Code Description Due Whom Code Comment ------------------------------------------------------------------------------- **-30457-B 33,000 B10 FINAL 06/28/04 PJP A W/CHRIS SBA BONDED TO GRD RING, ADD 3 ANT 00/00/00 **-18936-E 3,000 E01 SERVICE 05/21/04 CJD A ', a DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT Application is hereby: TOWN OF SOUTH WINDSOR PERNIIT# BUILDING DEPARTMENT APPRO 1540 SULLIVAN AVENUE Bldg.Permit# JU 644-2511 ext. 230 ©� Date Building Insp for Application must be printed or typed FEE SCHEDULE Location of Job: Street No. Street Lot No. Over$1,000= $15.00 per$1,000 or any fraction thereof Tenant Designation Apt.No. APPLICANT APPLICANT ADDRESS M'©k'�Hia±4 L/U JJ9\)Gr4Tt, C /C CT' 0(o:7'-7 8 APPLICANT PHONE# �Z C'33 �2C7 OS a OWN S OWNER OWNER ADDRESS P ' �.. OWNER PHONE ; ESTIMATED COST$ SC)O C ), 00 _ y �V IS THIS A CONTRACT COST? V Yes No FEE ENCLOSED$ ��SOR t C TYPE OF JOB: -XZI ew Installation _Alteration/Addition/Repair Revised 4/01//2002 APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side) TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A BUILDING PERMIT APPLICATION? 9'�ES ❑NO ❑RESIDENTIAL-' ❑BUSINESS❑ASSEMBLY CURRENT USE AND OCCUPANCY CeLL ❑MERCANTILE❑EDUCATIONAL FUTURE USE AND OCCUPANCY ❑INSTITUTIONAL ❑FACTORY ENGINEER'S NAME Pt PHONE goo- 252- ❑ STORAGE 0 GARAGE ADDRESS QX XED USE CITY P.C.!C� AA f STATE C ZIP (Other please specify) TYPE OF INSTALLATION/VVIRING METHOD rL eP JN(- SIZE OF SERVICE 2 CEO/)-! P SIZE OF MAIN CONDUCTORS_ NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS NUMBER OF PANELS�_ REMOTE DISCONNECT REQUIRED? ❑YES a-9 NUMBER OF LIGHT CIRCUITS NUMBER OF POWER CIRCUITS NUMBER OF SWITCHES NUMBER OF OUTLETS NUMBER OF LIGHT FIXTURES NUMBER OF HEAT CIRCUITS NUMBER OF A/C CIRCUITS SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED. DESCRIPTION OF WORK THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO COMPLY•WITItALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE PERFORMANCE OF SUCH WORK. Wit• 161 o3 , &�-- - ( C� CONTRACTORS LICENSE NO. TYPE STATE SIGNATURE OF APPLICANT DATE ' �� 6 Y Technical,Electrical&Communications,Inc. 35 Monahan Lane,Naugatuck,CT.06770 !Vcon�ctor CT.License #E1-104031 U Wednesday, May 19,2004 I Thomas A. Genovese E1-104031 give Jamie Genovese E2-184102 permission to take out an electrical permit to wire a telecommunication equipment for T-Mobile Wireless. This work requires a 200amp feed and from a existing meterbank to the communication equipment. BUILDING PERMIT# 30457 PROPERTY OWNER TOWN OF SOUTH WINDSOR 56 SAND HILL DRIVE SOUTH WINDSOR ,CT 06074 JOB LOCATION 151 SAND HILL ROAD SOUTH WINDSOR, CT 06074 Cost of Job $3000.00 Thank y u, Thomas A. Gen e Vice President Office: 203-720-0587 E-mail TECINC35na,aol.com Fax: 203-720-0629 STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION Be it known that THOMAS A GENOVESE 35 MONAHfAN LN NAUGATUCK,CT 06770 has been certified by the Department of Consumer Protection as a licensed ELECTRICAL UNLIMITED CONTRACTOR TYPE:EI i License # 104031 Effective: 10/02/2003 Expires: 09/30 2004 d s T.Fieming,Commissioner } Shirle Wilhelm -CRS A roval Confirmation: Request No. 342477 Pa e 1 From: <clpsvc@nu.com> To: <WILHEL@SOUTHWINDSOR.ORG> Date: 6/10/04 10:57AM Subject: CRS Approval Confirmation: Request No. 342477 Your approval of the following CRS Request has been successfully processed. CRS Work Request M 342477 House No: Lot No: Street Name: Town Name: SOUTH WINDSOR, CT Inspector: CHRISTOPHER DOUGAN Approval Date: Jun 10, 2004 This e-mail, including any files or attachments transmitted with it, is confidential and intended for a specific purpose and for use only by the individual or entity to whom it is addressed. Any disclosure, copying or distribution of this e-mail or the taking of any action based on its contents, other than for its intended purpose, is strictly prohibited. If you have received this e-mail in error, please notify the sender immediately and delete it from your system. Any views or opinions expressed in this e-mail are not necessarily those of Northeast Utilities, its subsidiaries and affiliates(NU). E-mail transmission cannot be guaranteed to be error-free or secure or free from viruses, and NU disclaims all liability for any resulting damage, errors, or omissions. APPLICATION FOR PERMANENT SIGN PERMIT Zt ingApproval:gA--rs 151 Sand Hill road Ref. f-1.1 -%A.� Est. Cost: $ 1 1fC' Final Inspectio.,n No. 30429 Permit Fee: $ c� •19 A`>! Building P' Approved: Zoning 8 3 Electric Permit# Applicant/Business Name Address Irl Iftio kook At Phone GYM'` 61-1 G Location of Sign Iti tAtA na, bntCL UGC, Zone TYPE of SIGN: ❑Wall or X Free-standing ❑ New or Q'Ieplacement Illuminated?E Yes ❑ No Proposed Sign Size(square feet)X Sign Height No.of Existing signs on site_I Free-standing Wall Description of sign materials and lighting: S'.s.y l�a-�- i Alct,�••�•w,... IBC, . ATTACH ()� C L 3 y DIAGRAM OF c�(w'an C& M C3t,t(1 :en+/nr_'rA- A SIGN INCLUDING I have read, understand and agree tolabide by the South Windsor Zoning Regulations, Signs DIMENSIONS Applicant a..~ 07 % ��Pi" —Date z•- s ''o y Property Owner �G1/%� d IG J •G•� : N,)1.+01— Date 2- ( -o 41 ��, _ Yam- � `�� .K,�"►5�`��� It Cry/Ju� '�----r-�.. [v+�►cr��"' f�` ' . ff 1 _.. _.:_.... I...._.... -� 8 9 F cr lWf�ll.{!lOJ�1-l3�1 PIOPuSed buddjn&&Sj, uses) andlor structure(s� as shown 0,11 this plan appearfs) to be in 0o41,orr nce ► Ith current South Windsc r rftulatiofm Variances and special, eXCOptions e Z Entor rr rit E tfsc ZBAk 4� ;; l Dq —C�C� —OT�vZ>vecf 2 ,� tit�t n .e�vlfrcxn� � UNDERGROUND 9tO RAGE PG. of STATE OF CONNECTICUr FACILITY NOTIFICATION 2. Department of Environmental Protection EPHM•6 NEW 10/85 .< UNDERGROUND STORAGE FACILITIES PROGRAM Z HAZARDOUS MATERIALS MANAGEMENT UNIT 3. FOR STATE A.SITE I.D. _O FIRST 165 Capitol Avenue,Hartford,CT 06106 a. NOTIFICATION AGENCY USE ONLY l TEL.556 4630 B.DATE RCVD BY D.E.P C.DATE ENTERED w OR TE LD. N SUBSEQUENT (if checked, PLEASE TYPE.ALL THREE COPIES MUST BE LEGIBLE! 4.: b. ❑ NOTIFICATION enter No.) Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form. D.GRID COORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS? LOCATION 5I NAME X Y ❑YES ❑NO NO.AND STREET - NEAREST iWfRsECTtNG STREET- CITY 64 TOWN d. OF FACILITY , M / ' ` /j STATE' S.LATITUDE r LONGITUDE BUSINESS NAME AN NAME / , L_ I Name NO.AND STREET CITY OR TOWN 6. MAILING ADDRESS "✓ovm W f 1,4P4J01Z. poll- el-& Pr STATE ZIP CODE TELEPHONE 00 NAME 1031 tA1..►O 1�I�t G l pA+O pcfr+-� i.Jt e.�R 4'-0'-. c.T Otero'7 c •Z NO.AND STREET O 7. FACILITY OWNER CITY OR TOWN STATE ZfP CODE TELEPHONE U N 8. TYPE OF OWNER ❑ PRIVATE ❑ STATE IXMUNICIPAL ❑ FEDERAL(G.S.A.No. OPERATOR/CONTAC 'NAME NO.AND STREET 9. PERSON CITY OR TOWN (,tJi{,.Lr.IAIM .�y/q�..t (7MlEl�' 0.10 STATE ZIP CODE TELEPHONE 10. 11°• ilb•"12a. 12 b.STATUS 13. TYPE OF 14. CONTENTS- 15.CONSTRUCTION 16.PROTECTION 17.INTEGRAL TANK ID. DATE OF Z TOTAL p I EST.QUANTITY DATE CONTENTS a: CHEMICAL NAME OF PRINCIPAL MATERIALS NAL 78. 19.FAILURE INSTALLATION o CAPACITY "'w TANK U b EXTERNAL PIPING SYSTEM e Z U I LEFT STORED o � a• b.DATE OF (Mo./Yr.) a� (Gals.) O¢ w LAST 0 o Q SUBSTANCE a v u ��a Q o w U O o MONITORING DETERMINATION w° Lu Z a 1 (if any). W O U p (not trade name.) r. INSTALLATION USED C9 O LL'.�= w O V "'a r= m 0 m OR SYSTEM CONDUCTED? m? I USED o_o- f= (Enter C.A.S. No.If known) o w a d— p Z x w o O U w u o Q Z w w r w w z-� 0-1E w ¢¢ _w v_ z m (It"YES",enter DATE„ ¢ I o (Mo./Yr.) w x O � m li a O`o Z Z ¢O O F r O E <p = REPLACEMENT O U y o U o U 3 ¢O o (Specify type and attach results). z o Ua t 0 a y (Mo./Yr.) from list 8) If"NO",enter"NO") Example 5/75 30 5000 X X Heating fuel#2 V y u 5 /� /� H 5/75 U NO Example 7/60 8000 X 8/78 X I,t,R, CAS#79016 Trichloroethane X X E 7 7/6 0 U _ 000 X NEA-nN66 OIL.* 2 X o ©000 LLI 20. HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? YES 22.CERTiFiCATIONi I certify under penatsy of layv that F have peracnapy a 0 2 1. COMMENTS; examined and am familiar wish fhe information subinrfted in this and oR anached 226.DATE-SIGNED documents and that based on my inquiry of those individuals in,tmediately;respgnabie wH for obtaining the inform 0600,1 iWiev'e that the wbthf#ed jnfomafion is true, accurate and.complete.Penalties:any aWner wfro kadwingly ,fenls,fo eotify shag be N subject to a civil penalfy,not to'exeeed S1ti far-6peh ton);for whisk notification ye 2td.OFFtC1At iRLE(of owner or authorized Is not given or for which false ihfoimation'rs su d2t.,rN (hype or Print) � ti > � repres e/ive), CO P I 2 : SEND TO LOCAL FIRE MARSHAL