HomeMy WebLinkAbout5 John Fitch Boulevard - UST - Fire Mars s
ECEIVE
APR I'8- 2011 0
` Notification for Underground StorWg914i ka,._
'CPPU USE'ONLY
App#:
Please complete this entire form,where applicable, in Doc#:
accordance with the instructions(DEP-UST-INST-001)to
ensure the proper handling of your notification. Print or type Check M '
unless otherwise noted.
Submit one notification form per site.
Part [: Notification and Fee Type
Check the appropriate box(es)identifying the notification type.
1. LOCATION of UST(s)
Name of site: South Windsor Sunoco
Street Address or Location Description: 5 John Fitch Blvd
City/Town: South Windsor State.- CT Zip Code: 06074
2. Site ID Number, if known:132-2271
3. T3 is notification is for(check all that app!y);. Fee- *Number of Tanks Total Fee
(a) (b) (a x b)
® An annual or first time notification $100.00/per tank 4 $400.00
❑ fee exempt tanks $0
❑ adding new UST system $100.00/per tank
❑ fee exempt tanks $0
❑ adding an orphan UST system (newly $100.00/per tank
discovered)
❑ fee exempt tanks $0
® update/correction to owner/site info $0
❑ update/correction to UST system info $0
❑ Permanent Closure of an UST system $0
Compar#menta/ized tanks are counted as one tank. *Total Fee $400.00
*For municipalities,the 50%Q discount applies. The notification will not be processed without the fee. The fee
shall be non-refundable and shall be paid by check or money order to the Department of Environmental
Protection.
DEP-UST-NOT-001 1 of 9 Rev.02/18/11
a
Part I1: Owner/Operator Information
if identifying an entity registered with the Secretary of the State,fill in the name exactly as it is shown on
such registration.
1. Owner/Operator Name: Alliance Energy LLC
Mailing Address: 404 Wyman St,Suite 426
City/Town:Waltham State: MA Zip Code: 02451
Business Phone: 781-674-7780 ext.: Fax: 781-674-7799
Contact Person: David Went Phone: 781-674-7780 ext.
Business Type(check one): ® private ❑ federal gov't ❑ state gov't ❑ local gov t ❑ tribal'
*Notification or fee is NOT required for UST systems located on tribal lands.
❑ Check if any co-owners. If so,attach additional sheet(s)with the required information as requested above.
Owner's interest in property or facility at which the proposed activity is to be located:
(check all that apply)
® storage tank owner ® billing contact ® property owner
® storage tank operator ® facility owner/operator ❑ other(specify):
2. List primary contact person in charge of tanks, if different than the owner.
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext. Fax:
Contact Person: Title:
Email:
3. List storage tank operator,if,different than the owner.
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext. Fax:
Contact Person: Title:
Email:
4. List billing contact, if different than the owner.
Name.Alliance Energy LLC
Mailing Address: 36 E Industrial Rd
City/Town: Branford State: CT Zip Code: 06405
Business Phone: 203-488-6068 ext. Fax: 203-488-7161
Contact Person: Mania Zabek Title:
Email: mzabek@allianceenergy.com
DEP-UST-NOT-001 2 of 9 Rev.02/18/11
Part II: Owner/Operator Information (continued)
5. Financial Responsibility
Other than through state funds, check the applicable box(es) by the following mechanisms to identify how
you have met financial responsibilities requirements. (check all that apply):
❑ Self Insurance ❑ Guarantee ❑ Bond Rating Test
gl Commercial Insurance ❑ Surety Bond ❑ Trust Fund
❑ Risk Retention Group ❑ Letter of Credit
❑ Local Government ❑ Other Method(specify):
Financial Test
Part III: Site Information
TYPE OF SITE(check all that apply):
❑ Air Taxi(Airline) ❑ Federal Non-Military ❑ Private
❑ Aircraft Owner ® Gas Station ❑ Railroad
❑ Auto Dealership ❑ Industrial ❑ Residential
M Commercial ❑ Local Government ❑ School
❑ Contractor ❑ Marina ❑ State
XI Convenience Store ❑ Municipal ❑ State Government
❑ Farm ❑ Other ❑ Trucking/Transport
❑ Federal ❑ Petroleum Distributor ❑ Utilities
❑ Federal-Military
DEP-UST-NOT-001 3 of 9 Rev. 02/18/11
Part IV: Underground Storage Tank Information
Complete for all tanks and piping at the subject location. If you have more than 5 tanks in one location, reproduce this
Part and complete for additional tanks.
flank tdentcation l+� e�' Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
B2R1 B3R1 B4R1 B5R1
isart iif a coinpartinentalized tank ❑ ❑ ❑ ❑ ❑
9: Status of Tank Currently in Use ® ® ® ® ❑
Temporarily,C sell, ❑ ❑ ❑ ❑ ❑
Bate temporarily Closed: "
Permanently Closed ❑ ❑ ❑ ❑ ❑
Z nergency Generator Use i my ❑ ❑ ❑ ❑ ❑
3 lath of1nstaiFation of Tank"(miarr#hTyear) 9/97 10/88 10/88 10/88
4. Gfe Expectancy 4 Tank years} 30 30 30 30
istirnated Total capacity of-rank(gallons 6,000 8,000 8,000 8,000
6 YSubstaice curtentiy Store�;in Tank(or last: '
stored In.the case of dosed tanks
Gasoline. ❑ ® ® ❑ ❑
Diesel ❑ ❑ ❑ ® ❑
Kerosene' ® ❑ ❑ ❑ ❑
Heating Oil(on-site consumption) ❑ ❑ ❑ ❑ ❑
Heating flil(for resale)' ❑ ❑ ❑ ❑ ❑
Used ail ❑ ❑ ❑ ❑ ❑
Gasohol ❑ ❑ ❑ ❑ ❑
Biofuell ❑ ❑ ❑ ❑ ❑
If Other,please specify here`
Hazardous Substance. ❑ ❑ ❑ ❑ ❑
CERCLA name and/or CAS;Number
Mixture of Substances' ❑ ❑ ❑ ❑ ❑
Please specify substances here
Material of constructiiori of"Tank
Asphalt Coated or Bare Steel ' ❑ ❑ ❑ ❑ ❑
Coated and Cattx dica'lly.Protected Steel(STI-�P3); ❑ ❑ ❑ ❑ ❑
Composite(Steel clad"with Fiberglass) ❑ ❑ ❑ ❑ ❑
Composite(Steel with Plastic Jacket) ❑ ❑ ❑ ❑ ❑
Composite(Steel with Urethane) ❑ ❑ ❑ ❑ ❑
Fiberglass Reinforced Plastic ® ® ® ® ❑
tither(e.g:,coitcre#e;etc.)(please specify)
DEP-UST-NOT-001 4 of 9 Rev. 02/18/11
Part IV: Underground Storage Tank Information (continued)
y ,Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
KT, antar» t�cirbr
- s �_�'B2RI B3R1 B4R1 B5R1
-T-Fart�#a cra�rtsnenta tank ❑ ❑ ❑ ❑ ❑
7 l late iai of Go4 stri v4i o0io-44 i4iiD �d)
Lr nfer�or ❑ El ❑ ❑ ❑
E El 11 El El El
bc�ub 111/aIle, ® ❑ ❑ ❑ ❑
Taok Nlarr�aer
Check box r€tank has ever Je `�paired ❑ El ❑ El
8 Prtmary Release Mtectlon Tank ... ..
Annual Preclsi�in:Tightn 'St est g° ❑ ❑ ❑ ❑ ❑
Tank Tightness Test with lnventoKy'�Coritrot; ❑ ❑ ❑ ❑ ❑
Confirivous ;Elecfroriid)Intemiffial M nitvnng.. ❑ ❑ ❑ ❑
A7G tritCstrf►al Mani#wring: ❑ ❑ ❑ ❑ El
ATG-CSl D—Contsnuors uth fs�rentory ❑ ❑ ❑ ❑ ❑
ReconcilratioaafConfrol
ATG-Static with Inventory ReconctliatroEtlControl ❑ ❑ ❑ ❑ ❑
Monfhly GroundwaterlUapor Monitoring'"-:! ❑ ❑ ❑ ❑ ❑
Manrrzl Tank-Gauging; '„ ❑ ❑ ❑ ❑ ❑
Monthly Visual rn#er tltial Mi nitoring', El El El El ❑
Autornat c Tank Gauging;" ❑ ® ® ® ❑
No release detection required(see►nstrucfii t s}; ❑ ❑ ❑ ❑ ❑
If Other Meth6d,:please 5pe8lty'here .
Piping Construction
9 Piping Installation Date' 9/97 10/88 10/88 10/88
16. Piping Material
Bare Steel ❑ ❑ ❑ ❑ ❑
Galvartized Steel ❑ ❑ ❑ ❑ ❑
1�0 Coated Steel ❑ ❑ ❑ ❑ ❑
Flexiiblix Plastic; ® ❑ ❑ ❑ ❑
No Piping associated with Tank or,Above GroOnd Only ❑ ❑ ❑ ❑ ❑
Fiberglass Reinforced Plastic' ❑ ® ® ® ❑
Semi=Rigid Plasfic ❑ ❑ ❑ ❑ ❑
_Copper ' ❑ ❑ ❑ ❑ ❑
Containment Sumps at Dispensers El ❑ ❑ ❑ ❑
Containment Sumps at Tanks, ❑ ❑ ❑ ❑ ❑
Metallic Fitting Isolated€rorr Sorl an- water El El El El El
Metallic Fitting Cafhodically l?rofected ❑ ❑ ❑ ❑ ❑
DEP-UST-NOT-001 5 of 9 Rev. 02/18/11
Part IV: Underground Storage Tank Information (continued)
Iank Id>3t�tt#Icatusn � Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
B2R1 B3R1 B4R1 B5R1
Part o€�` grpartentalrra task El El El El El
�{}'Piing Material°iCbntrntd) ' '
Cathpdically,Prr2tec#ed ❑ ❑ ❑ ❑ ❑
Qouble Wailed ® El El ❑ El
l3nknown ❑ ❑ ❑ ❑ ❑
If Other please specify,here
ft Piping Type(rust Bieck rind for each tank)
Pressure. x ® ® ® ❑
1 SA motion tvalve at tank)` ; ❑ ❑ ❑ ❑ ❑
No ttriciergrornd Prrduct Piping or Gravity Feed Only ❑ ❑ ❑ ❑ ❑
"Suction oo valve at tank)` ❑ ❑ El El El
CtaerC box rf prpFri ,has ever been repaired ❑ ❑ ❑ ❑ ❑
1-4 Pr➢maryAelease Dete'c#ion-Piping
Annual,Preotslor Line Tightness Testing ® ® ® ❑
Continuous(060'ronic)interstitial Monitoring ❑ ❑ ❑ ❑ ❑
Mont VisualInterstitial'Moniloring ❑ ❑ ❑ ❑ ❑
GroundwaterNapor Monitoring; ❑ ❑ ❑ ❑ ❑
PLLD-=:Annual l abb Leak Test ❑ ❑ ❑ ❑ ❑
PLLD-Monthly"Eiec.0,29ph Leak Testing ❑ ❑ ❑ ❑ ❑
Precision Line Tightnt?ss Testing Every years ❑ ❑ ❑ ❑ ❑
Statistical Inventory Reconciliation(SIR) ❑ ❑ ❑ ❑ ❑
Automatic Line Leaf Detectors ❑ ❑ ❑ ❑ ❑
Electronic Auto Line Leak Detectors ❑ ® ® ® ❑
Mechanical Auuto Line Leah Detectors ® ❑ ❑ ❑ ❑
No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑
If Other Method,please specify here
13. Spill anti Overfill Protection
Overfill Device installed
Audible Alarm ❑ ❑ ❑ ❑ ❑
Ball Float Device ❑ ❑ ❑ ❑ ❑
Rapper Device ® ® ® ® ❑
None' ; ❑ ❑ ❑ ❑ ❑
Other(please specify)',
Spill Device Installed ® ® ® ® ❑
DEP-UST-NOT-001 6 of 9 Rev. 02/18/11
Part V: Permanent Tank Closure
tHi
' attku 'den cat on
��, Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Part of�a eomp artmentalized tank ❑ ❑ ❑ ❑ ❑
1: GeneraF n of idi Tank,
Cite ofInstaltatiop{month/year)
1=stimated Total Ca�iad�ty(galio�lslyear)
Estimated date tank dosed(month/dayfyear)'
{ h6ck one per tank)
Tank from ground ❑ ❑ ❑ ❑ ❑
Tank was.aoaed in ground ❑ ❑ ❑ ❑ ❑
Tank filled vvtti inert Material ❑ ❑ ❑ ❑ ❑
Describe the'inert fits material here
2. Estimated dateAhe UST was last used for
storing regulated substances( onth/daylyear)
3„ Site Assessment.
Required Site Assessment Completed ❑ ❑ ❑ ❑ ❑
(If Yes,provide consultant/contractor information-below)
Consultant/Contractor Name(s)
:Consuttant/Cohtractor Addresses(s) ,
Consuttent/Contractor Phones)
Soil Samples Collected and Analyzed for one or more of..' El El ❑ ❑ ❑
the fbHbwing: VOCs,SVOCs,Metals,ErPH
Groundwater Encountered During Assessment' ' ❑ ❑ ❑ ❑ ❑
Groundwater Samples Collected and,Analyzed for one or El El El El Elmore of the following: VOCs,SVOCs,Metals,ETPH
*Soil Samples had Constituents of Concern above the
following RSR Criteria:
GA PMC ❑ ❑ ❑ ❑ ❑
GB PMC ❑ ❑ ❑ ❑ ❑
Res DEC ❑ ❑ ❑ ❑ ❑
I/C DEC` ` ❑ ❑ ❑ ❑ ❑
*If:any boxes were checked,include a table summarizing
the data and highlighting the exceedances (See R.C.S.A.
Sections 22a-133k-1 through 3 for definitions).
*Groundwater Samples had Constituents of Concern above
the fotlo wing RSR':Criteria.
GWPC ❑ ❑ ❑ ❑ ❑
SWPC ❑ ❑ ❑ ❑ ❑
Res GWVC ❑ ❑ ❑ ❑ ❑
i/C GWlC ❑ ❑ ❑ ❑ ❑
If any boxes were checked,include a table summarizing
the:data and,highlighting the exceedances (See R.C.S.A.
Sections 22a-133k-1 through 3 for definitions),.
DEP-UST-NOT-001 7 of 9 Rev.02/18/11
1
Part V: Permanent Tank Closure (continued)
'tank,I�errtrftcatjon NuY��r ".
Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Part of a cc►mpat"tar",d wIt," ❑ ❑ ❑ ❑ ❑
R liie ai It iz�tts I rmenrtef!'by Enmrc nrrientaf,
Consuitant/G{u tr$dor ❑ ❑ ❑ ❑ ❑
If box r&checked,a closure report must. subrtl3ited to thaw'
t t1ST Door llnation Progtari�fp elJatuatttan:'
Remedial"l�cti4ns. arppleted
ff box is checked,a closure report must be submitted to the El ❑ El El
LUST Coordination Program for evil flon.
Part VI: Certification of Installation
Complete within 30 days of installing an UST or adding an UST system to an existing notification. If you have more than 5
tanks in one location, reproduce this part and complete for additional tanks.
Tank Iderittfrcation Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Fart of a Compartmentalized Tank. ❑ ❑ ❑ ❑ ❑
Installer of tank and piping must check all that apply ! ❑ ❑ ❑ ❑ ❑
Installer certified by tank and piping man f cturers ❑ ❑ ❑ ❑ ❑
'Installation inspected by a.req*tere.Onq#i eer ❑ ❑ ❑ ❑ ❑
Installation inspected and approved by implementing ❑ ❑ ❑ ❑ ❑
agency
Manufacturer's installation checklists have been El El El El Elcompleted
If Other Method,please specify here
Provide signature of UST Installer to certify proper installation of subject UST System.
Signature of UST Installer Date
Name of UST Installer (print or type) Title
Company Name
DEP-UST-NOT-001 8 of 9 Rev.02/18/11
Part VII: Owner/Operator Certification
The owner/operator and the individual(s)responsible for actually preparing the notification must sign this part.A
notification will be considered incomplete unless all required signatures are provided.
"I have personally examined and am familiar with the information submitted in this document and all
attachments thereto,and I certify that based on reasonable investigation,including my inquiry of the
individuals responsible for obtaining the information,the submitted information is true,accurate and complete
to the best of my knowledge and belief.
I understand that a false statement in the submitted information may be punishable as a criminal offense, in
accordance with section 22a-6 of the General Statutes,pursuant to section 53a-157b of the General Statutes,
and in accordance with any other applicable statute.
I certify that this un rground storage tank notification is on complete and accurate forms as prescribed by
the commissi thou teration of the text
31r 1/1
Si re of ner/Ope for Date
John Gargano Executive Vice President
Name of Owner/Operator(print or type) Title(if applicable)
Zf
Sign a of P epa (if differen# n above) Da e
Megan Kazmierczak Compliance specialist
Name of Preparer(print or type) Title(if applicable)
❑ Check here if additional signatures are required. If so,please reproduce this sheet and attach signed
copies to this sheet.
Note: Please submit a completed Underground Storage Tank Notification and all Supporting Documents to:
CENTRAL PERMIT PROCESSING UNIT
DEPARTMENT OF ENVIRONMENTAL PROTECTION
79 ELM STREET
HARTFORD, CT 06106-5127
A copy of this completed Notification Form must also be forwarded to the local fire marshal.
If you have any questions,please contact the UST Program at 860-424-3374 or by a-mail(DEP.USTFeena ct.gov)
DEP-UST-NOT-001 9 of 9 Rev.02/18/11