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Home My WebLink About5 John Fitch BLVD - UST - Fire Marshal C H- se 588 SILVER STREET AGAWAM, MA 01001 TEL 413 J89.3530 FAX 413.789.2776 WWW.ECSECLIPSE,CCM EC"!w--"VIE To Whom It May Concern: BY: Eclipse, a Division of ECS, Inc. is an environmental and compliance consulting firm that assists clients with their storage tank compliance programs. In this role, I have enclosed amended permit,registration and/or license items and applicable fees(if required)that show a change in owner and/or operator for the facilities on the forms, effective March 1, 2012. If you have any questions about this transfer, or if any further information and/or additional fees are needed, please feel free to contact us at the phone number below. If a new item will be issued by your agency as a result of this change, our client requests that after your office has completed processing of the paperwork,the new document be sent to our office at this address: Eclipse,a Division of ECS,Inc. Attn: Eclipse staff 588 Silver Street Agawam, MA 0 100 1 Thank you for your assistance with this matter. Please do not hesitate to contact a member of our Eclipse staff at 413-789-3530 or me at 614-433-0170 with any questions or concerns. Sincerely, Eclipse, a Division of ECS, Inc. Megan Kazmierczak Senior Compliance Manager Notification. for Underground Storage Tanks CPPU USE ONLY App M - Please complete this entire form, where applicable, in Doc M abe idance With.the instructions-(DFp-1 IST-MST-001)to ensure the proper handling of your notification. Print or type Check M unless otherwise noted. Submit one notification form per site. Part I: Notification and Fee Type Check the appropriate box(es) identifying the notification type. 1. LOCATION of UST(s) Name of site: Global Montello Group#71 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. This notification is for(check all that apply): Fee *Number of Tanks Total Fee= (a) (b) (a x b) ❑ An annual or first time notification $100.00/per tank ❑ 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 Compartmentalized tanks are counted as one tank. *Total Fee For municipalities, the 50% 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 Part II: Owner/Operator Information If identifying an entity registered with the Secretary of the State, rill in the name exactly as it is shown on such registration. 1. Owner/Operator Name: Alliance Retail LLC Mailing Address: 404 Wyman St, Suite 425 City/Town: ► altham. State: 1VlA =-dip 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: Global Montello Group Corp. Mailing Address: 404 Wyman St., Suite 425 City/Town:Waltham State: MA Zip Code: 02451 Business Phone: 781-674-7780 ext. Fax: 781-674-7799 Contact Person: David Went Title: Environmental Compliance Mgr. Email: dwent@allianceenergy.com 4. List billing contact, if different than the owner. Name: Alliance Retail LLC c/o ECS Eclipse Mailing Address: 120-L Lakeview Plaza Blvd. City/Town:Worthington State: OH Zip Code: 43085 Business Phone: 614-433-0170 ext. Fax: 614-433-0217 Contact Person: Megan Kazmierczak Title: Senior Compliance Mgr. Email: mkazmierczak@ecseclipse.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 r ❑ Commercial Insurance `❑ Sureiy isund ❑ Trust Furid ❑ 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 ® Commercial ❑ Local Government ❑ School ❑ Contractor ❑ Marina ❑ State ® 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. Tank Identification:Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: B2R1 B3R1 B4R1 B5R1 Part of a compartmentalized tank .' ❑ ❑ ❑ ❑ ❑ Tank Construction 1. Status of Tank Currently in Use ® ® ® ® ❑ Temporarily Closed ❑ ❑ ❑ ❑ ❑ Date Temporarily Closed Permanently Closed ❑ ❑ ❑ ❑ ❑ 2. Emergency Generator Use Only ❑ ❑ ❑ ❑ ❑ 3. Date of installation of Tank(month/year) 9/97 10/88 10/88 10/88 4. LifeExpectancy of;Tank(years) 30 30 30 30 5. Estimated Total Capacity of Tank(gallons) 6,000 8,000 8,000 8,000 6. Substance Currently Stored in Tank(or last stored in the case of closed tanks) Gasoline ❑ ® ® ❑ ❑ Dlesel ❑ ❑ ❑ ® ❑ Kerosene ® ❑ ❑ ❑ ❑ Heating Oil(on-site consumption) ❑ ❑ ❑ ❑ ❑ Heating Oil(for resale) ❑ ❑ ❑ ❑ ❑ Used Oil ❑ ❑ ❑ ❑ ❑ Gasohol ❑ ❑ ❑ ❑ ❑ Biofuel ❑ ❑ ❑ ❑ ❑ If Other,please specify here Hazardous Substance ❑ ❑ ❑ ❑ ❑ CERCLA name and/or CAS Number Mixture of Substances ❑ ❑ ❑ ❑ ❑ Please specify substances here 7. Material of Construction of Tank Asphalt Coated or Bare Steel ❑ ❑ ❑ ❑ ❑ Coated and Cathodically Protected Steel(STI-P3) ❑ ❑ ❑ ❑ ❑ Composite(Steel clad with Fiberglass) ❑ ❑ ❑ ❑ ❑ -Composite(Steel with Plastic Jacket) ❑ - ❑l _.. - ❑ ❑ 11 Composite(Steel with Urethane) ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ' ® ® ® ® ❑ Other(e.g.,concrete,etc.)(please specify) DEP-UST-NOT-001 4 of 9 Rev.02/18/11 Part IV: Underground Storage Tank Information (continued) Tank Identification Nu 11 mber Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: B2R1 �B3R1 B4R1 B5R1 Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ 7. Material of Construction of Tank(continued) Lined ntenor ❑ .❑ _ ❑ ❑ n _ Excavation Liner ❑ ❑ ❑ ❑ ❑ Double Walled ® ❑ ❑ ❑ ❑ Tank Manufacturer Check box if tank has ever been repaired ❑ ❑ ❑ ❑ ❑ 8. Primary Release Detection-Tank': Annual Precision Tightness Testing ❑ ❑ ❑ ❑ ❑ Tank Tightness Test with Inventory Control ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ! ® ❑ ❑ ❑ ❑ ATG Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ ATG-CSLD Continuous with Inventory ` El ❑ El ❑ Reconciliation/Control ATG-.Static with inventory,Reconciliation/Control ❑ ❑ ❑ ❑ ❑ Monthly Groundwater/Vapor Monitoring ❑ ❑ ❑ ❑ ❑ Manual Tank Gauging ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Automatic Tank Gauging ❑ ® ® ® ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method,please specify here Piping Construction 9. Piping Installation Date 9/97 10/88 10/88 10/88 10. Piping Material Bare Steel ❑ ❑ ❑ ❑ ❑ Galvanized Steel ❑ ❑ ❑ ❑ ❑ Epoxy Coated Steel ❑ ❑ ❑ ❑ ❑ Flexible Plastic ® ❑ ❑ ❑ ❑ No Piping associated with Tank or Above Ground Only ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ` ❑ ® ® ❑ Semi-Rigid Plastic ❑ ❑ ❑ ❑ ❑ Copper ❑ ❑ ❑ ❑ ❑ Containment Sumps at Dispensers ❑ ❑ ❑ ❑ ❑ Containment Sumps at Tanks ❑ ❑ ❑ ❑ ❑ Metallic Fitting Isolated from Soil and Water ❑ ❑ ❑ ❑ ❑ Metallic Fitting Cathodically Protected ❑ ❑ ❑ ❑ ❑ DEP-UST-NOT-001 5 of 9 Rev.02/18/11 Part IV: Underground Storage Tank Information (continued) Tank Identification Numiser, Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: B2R1 83R1 B4R1 B5R1 Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ 10. Piping Material(continued) Cathodically Protected ❑ n ❑ ❑ n Double Walled ® ❑ ❑ ❑ ❑ Unknown - ❑ ❑ ❑ ❑ ❑ If Other,please specify here 11. Piping Type(must check one for each tank) Pressure ® ® ® ® ❑ "U.S."Suction(valve at tank) ❑ ❑ ❑ ❑ ❑ No Underground Product Piping or,Gravity Feed Only ❑ ❑ ❑ ❑ ❑ "Safe"Suction(no valve at tank) ❑ ❑ ❑ ❑ ❑ Check box if piping has ever been repaired ❑ ❑ ❑ ❑ ❑ 12. Primary Release Detection-Piping Annual Precision Line Tightness Testing ® ® ® ® ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Groundwater/Vapor Monitoring ❑ ❑ ❑ ❑ ❑ PLLD—Annual Agph Leak Test ❑ ❑ ❑ ❑ ❑ PLLD-Monthly Elec.0.2gph Leak Testing ❑ ❑ ❑ ❑ ❑ Precision Line Tightness Testing Every 3 years ❑ ❑ ❑ ❑ ❑ Statistical Inventory Reconciliation(SIR) ❑ ❑ ❑ ❑ ❑ Automatic Line Leak Detectors ❑ ❑ ❑ ❑ ❑ Electronic Auto Line Leak Detectors ❑ ® ® ® ❑ Mechanical Auto Line Leak Detectors ® ❑ ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method,please specify here 13. Spill and Overfill Protection Overfill Device Installed Audible Alarm ❑ ❑ ❑ ❑ ❑ Ball Float Device ❑ ❑ ❑ ❑ ❑ Flapper Device 0 ® ® ❑ None ❑ ❑ ❑ ❑ ❑ Other(please specify) Spill Device Installed ® ® ® ® ❑ DEP-UST-NOT-001 6 of 9 Rev.02/18/11 Part V: Permanent Tank Closure Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ 1 General Information of Closed Tank 27 bate of Installation;(month!imr) Estimated Total Capacity(gallons/year) Estimated date tank closed(month/day/year) (check one per tank): Tank was removed from ground ❑ ❑ ❑ ❑ ❑ Tank was closed in ground ❑ ❑ ❑ ❑ ❑ Tank filled with inert material ❑ ❑ ❑ ❑ ❑ Describe the inert fill material here 2. Estimated date the UST was last used for storing regulated substances(month/day/year)' 3. Site Assessment Required Site Assessment Completed ❑ ❑ ❑ ❑ ❑ (If Yes,provide consultant/contractor information below) Consultant/Contractor Name(s) Consultant/Contractor Addresses(s) Consultant/Contractor Phone(s) Soil Samples Collected and Analyzed for one or,more of ❑ ❑ ❑ ❑ ❑ the following: VOCs,SVOCs,Metals,ETPH Groundwater Encountered During Assessment ❑ ❑ ❑ ❑ ❑ Groundwater Samples Collected and Analyzed for one or ❑ ❑ ❑ ❑ ❑ more 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 following RSR Criteria: GWPC ❑ 0 ❑ ❑ ❑ SWPC ❑ ❑ ❑ ❑ ❑ Res GWVC ❑ ❑ ❑ ❑ ❑ I/C GWVC ❑ ❑ ❑ ❑ ❑ *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 Part V: Permanent Tank Closure.(continued) Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Remedial Actions Recommended by Environmental Consultant/Contractor nor.:„ ;s „-ckad,'a closure repo rt'must be submitted w n ❑ � ❑ n LUST Coordination Program for evaluation. Remedial Actions Completed If box is checked,a closure report must be submitted to the ❑ ❑ ❑ ❑ ❑ LUST Coordination Program for evaluation. 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 Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a Compartmentalized Tank ❑ ❑ ❑ ❑ ❑ Installer of tank and piping must check all that apply ❑ ❑ ❑ ❑ ❑ Installer certified by tank and piping manufacturers ❑ ❑ ❑ ❑ ❑ Installation inspected bya registered engineer ❑ ❑ ❑ ❑ ❑ Installation inspected and approved by implementing ❑ ❑ ❑ ❑ ❑ agency Manufacturer's installation checklists have been ❑ El ❑ ❑ ❑ completed 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 su mltted in is ocu,men an -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 �eiief: - 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 underground storage tank notification is on complete and accurate forms as prescribed by the commjLs,%pner without alteration of the text." February 16, 2012 Signature of Owner/Operator Date Steve Charron Environmental Manager Name of Owner/Operator(print or type) Title(if applicable) Signatu[�:U'YV Pretrbl different tI above) Date Megan Kazmierczak Senior Compliance Mgr. 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 e-mail (DEP.USTFee(g)ct.g'ov)- DEP-UST-NOT-001 9 of 9 Rev. 02/18/11