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HomeMy WebLinkAbout40 Kennedy Road - UST - Fire Marshal Connecticut Department of Energy &Environmental Protection Bureau of Materials Management & Compliance Assurance Emergency Response & Spill Prevention Division Notification for Underground Storage Tanks Please comnplete this form, in accordance'with the Iagajd= (DEOP t1S't-1w-601)to.:ensure the Proper handling of your notification,.Print or{ype unless otherwise noted. t>h+ ei> #. Submit one nofificafion;form persita: 00 � Part 1: Notification and Pee Type Check the appropriate box(es)identifying the notification.type. 1. t:QCAATION of-UST(s) Name of site; Street Address or location Description: 9 City/Town: d-/At /.lr _ nA jaig Mate, zip Code: 2 t, 2 Site:l;D.Number, 3 Tht$ totificafJoti isox � z � Toni c1loose , G' ZtJc ; i} first time site notification[newt $10000# , (Complete entice application) tank it) annual notification treo with NO $100.001 modifications tank (Complete Farts I and Vll only) (❑ 111) annual notification(ran u t)with $100.00/ modifications,(specify modifications under iv tank below) I PAN (Complete Parts I and Vll and modifications only) iv) a to an existing notification;check any of the following to.specify. (Complete Parts I and Vll '' only Q adding new UST system(Part IVY Wo..otl/ tank DEEP-UST-NIOT-001 1 of 12 Rev.09/2811 Part is Notirication and Fee Type (continued) if F : as e inrtiydrftcattonsrtufig mkt It V519 Mg Q adding an orphan LIST system(newly $100,00/ discovered)(Part iV3 tarn updatelcorrection to Part ll: { er ownertoperator infalflrlancial responSibilify transfer of ownership(Part Il) to ❑ update/correction to part Ui,record inF6 ;} � W ..r- ❑ update%grrectron.to Part IV:UST system $0 � Info 0 Permanent Closure of an UST system $0 (Part c s JAI `t`or municipalities,the0°!c disc+3unt alkalies.The notification will..not:be processed without the fee.7#ae fee shall be non-refundable and shall.be paid by check or money order to the Department of Energy end Environmental Protection. Part 11: Owner/Operatar in€ormatian W on Ownerlbperatarls a cO porattofr,lirr'trted liabijil y dompany 11mit6d parfnershlp,fimlted tlabltity paffnership,.ore ag iti otytrust, d.with be registered with the Secretary of State.if applidable;the applicant`s na ne.shalf be slated exactly as ltisra3glstered.'with-the`Secrra'taly of State.l?lease Irate,forthose'entltles registered with the Secretary of state,the:: registered name wilt ba-the name,used sedAY O�EP.This information can be accessed at the-Secretary of States database(Ct}1Vt/�17J.(wrw arrl41y. t3afRt�1ax< l 0 1f an Ownarloperatorls an individual,Provide the legal name(lndude r;ultlicJ in the firllowing""format:First Name,-M1rl* initial;Lasf Named Six(Jr,Sr.,!!"f11,etc)., 1'. UST Owner Noma; Ar b C)t CAO IJAJA h J h i6 Z` &A4 1 1N . Mailing Address: /b to e b E'X i i tf i Cityfrown Afoa#j 7BaNSti too State: A;- Zip Code: Business Phone: ; � MrS Sy l»« ext Contact Person: Phone:; ,�'�� Y .�if G tt t�,�i ext. *E-rrla L eA i r:t'A O"P,Ii*iK i r4-r-'K I Loot *13y providing this e-mail address you are agreeing to redeiue Official correspandenee from the department;at this adtlress,concerning the subject appiioafion.Please remember to check your security,settEngs to be',cure YOU can receive a-mails from``.ct;goV addt'esses.Also,please notify the depar lment if youra-maii address changes: a} Business Type(check one): [ individual ❑ federal agency 0 state agency ❑ municipality Q '*tribal [ "business entity(*If a business entit cvrnplete i through lii): DEEP-UST NOT-001 2 of 12 rev.09J2811 x` Part II. Owner/Operator Information i) check tl.pe: corporation ❑ limited liability company ❑ limited partnership limited liability partnership ❑ statutory trust ❑ Other: ii) provide Secretary of the.State business ID#; ' This information can be accessed at the Secretary of'State's database(CONC©!?ifl.{ cord o >c v1 iii) [] Cheek here 9 your business s;NOT registered with the Secretarygf-State's office; "Notification or fee is MOT required for USTsysternq located an tribat lands. Z; UST Operator,if different than UST owner Name.' Mailing Address: City/Town: state:> ZIP code:: Business Phone: ext.: Contact Person:: Phone: :ext. *�-rrtalt:> a) Business Type(check one): ❑ Ir di*ual ❑ federal agency ❑ state;agency D municipality ❑ "tribal. ❑ "business entity;(*If a business entity complete i through iii): I} check type. ❑,corporation ❑ limited liability company ❑ limited partnership' limited liability partnership ❑ statutory trust ❑ Other: il} provide Secretary of the Stato business Ili#: This information can be accessed at the Secretary of State's database(CONCORDI.( ,co c rd-so . ov Ct)NC iii) :[j Check-bore:if your business is NOT registered with the Secretary"of'State's office. -Notification or fee is NOT required for UST systems locatoil on trtbal..'lands Check if any co-owners/operators.if so attach additional sheet(s)with the required Information as>mq.uested above. 3. Billing contact,if different than UST owner. Name: l r, j;X aleoijV0 MailingAddresa: S#yre2at+ #e+lf'rtL. �t ArZr�faU7 Cityfrowm State- 04 Zip Code: JrlAe Business Phone: V/ 7.3447 ext.: Contact Person: AlhAle y CAVMDAlr Phone:: ext. E-mail: 4. Prizna.y contact,If dlfferent than UST owner Name �' A 7 f E}t3 r . nl#f/q a AtMV fV r'1� 1fr r S /#� TJsf >u Mailing Address= /00s e,0 4)e Ae/i1 City/Town: MODAf r, 4 W1R State:A4 dip Code; 1-!;/ Business Phone: 111,L,, Z&z, 73 q 7ext.; Contact Person; � C ��of t/r?�tD47 Phone: ext; "E-mail: 11O. , beAUMVv to )( f? "By providing this a-mail address you are agreeing to recelve off e'ral correspondences frorii the department,at this electronic address,conceming the subject application_Please remember to check your security settings to'be sure; you can rebeive e�mais from"ct.gov"addresses.Also,please notify the department if your e-mail address:changas. REEF UST-NOT-001 3 of 12 Rev.0912S/42 Part If: OwnerfOperatar informati€sn(continued) 5. Property Owner,if different than UST owner Nome: Mailing Address. oitytrlown State: Zip Code:: Business Phone: ext. Contact Person: Phone.' a ct. E-mail 6. Class A Operator: mast be the individual who wan trained. Name: 111AAMY 6,6A1e*VA11r Mailing Address: 0a'a r-sz t)c bwvr Clyfrown; MDOlj Stag: Zip code. <i Business Phone: ,6 7 �3i/—j 'ext.: Company Name,if applicable: Approved Training Course: ./NC r,#AI 9r0 047 e 09,.#4_ Training Bate: �- � Winitial or biennial training EAR: d .retraining ordered for eon-cornpliance Certification Expiration Bate: Class A Operator'sSignature; 7. Class B Operator; must be the In lvidual who was trained. Names l ?'f+de4 tl J T Mailing Address: Za-6 CA rlAI b Al sWd Cityfrown:, .1 ;V444D R41 N j9d k) /6,4 State s,' "` Zip Code: 6 4,6 ., Business Phone: exf,; E-mail- 84 - zfS Company Name,if applicable: Approved Training Course , Training mate: initial or bier�rilal training OR 0 retraining ordered for non-compliance Certification Expiration©ate: Class 8 Operator's Signature: DEEP-LIST-NOT-obi 4 o€12 Rev.09/28112 part lh ownerlopewor Irnfarination(4ontin' e ) a. property Owner,if different than UST owner Name.* Boling Address; CityfToym: State; Tap Code: Business Phone, ext. otrtact Person;: Piic riei exL E-fn iB. r s p-00trator. rnusf ire the indlvldual wt omus trained. Maine, IV4AIIV &A& "Af IVtailing Address: 10440 A�44 1 .� . rqs Code / r I�! A �tyi'Town: D �v� / �vN��t State Bustiess Phone. y/Z� 24 L ,73 if 7 . Ap�sraves Training Course: r - : Training De'W, or blenrsiat Q retraining ordered for -mmoliar CerltT"lo.q EVkaWn data: Cuss A 00arator's Signature: T. Ctass B t-per c K must lae the Individual why=was iyraln'ed. Name, N k7`/ ,u Tice'' Mailing Address; rd Q CK t i:N S we, - zip coda. 4 A 5� l usl ess Phana, wd.; ©ritrl . sw c4t-i Compom Ndrii6,,i!applicable: App d Training Cuur Training Data; d' ini#isi ar biennial trairfrtg I�R retraining c irdered for non-coMilance Certit'+oadon Expiration bates CTaes S 4pemto.es SEgnature; MEP-MT-NOT-00i 4 of 12 Rev.t1SM12 Part II: Owner/Operator Information(continued S. Financlal Mechanisms}. Complete the table below identifying the financial.assurance mechanisms) used to demonstrate financial responsibility;%s specified in the Federal Register, Use the list of surety types below.If an`other method`is chosen;please specify the method in the table. A Self Insurance Guarahtee. 1. Trust Fund B. Corrimerclal Insurance F. Surety Bond' J. ':State Fund C. Risk Retention Group G. Letter of,Credit K, Other Method(specify in- C. Local Government H. Bond Dating Test table below) Financial Test *Pursuant to section 262 of Public Act 12-1 of the June 12Rh Special Session,the state fund(UST Petroleum Clean-Up Program)will cease to serve as a financial responsibility mechanism on. • October 1,2012,forthose u+rho own or operate USTs on more fan five separate<sl#es;and .; October 1,201.3 for municipalities and for those who own or operate USTs on-five or less separate altes -i'- e Owners/ shall complete the attached"Certlfication of financial.ResponslbAity Form"and maintain such completed form at the facility where the-storage tank system(s)are located.THIS FORM DOES NOT NEED TO BE SUBMITTEa but must be updated to reflect any.phanges Part III: `Record Information Off Site StarageW Records at a Centralized Location Does the owner/operator of more than 10 facilities,with tJST systems reques#to store:certain records tat a centralized location? Yes ❑ No If yes:,provide the central locationn address-below. Name of Location. rit,c, ax'sa}d,l Owl JUNt%ki LL ! S bAgtor. Address: /D., j;�A>r Citylrown: / p ,j rjcJrjSA;j p Stater ` Zip Code; 1 ax'I Such records must be immediately available for inspection by the commissioner or the commissioner's designee at any such central location, Please refer to section 22a-449 q CGS;for storage of underground stottiage tank system records that ruby be kept at a centraftw location or that must be kept on site: DEEP-UST-NOT-1501 5 of 12 Rev.09128/12 Part IV: Underground Storage Tank Information 'bib mple#e#or all tanks;and piping a#the subject 1006tion. Begin by labeling tanks(including compartments-,if applicable).Label tanks as required by the instructions. .:if you have more than 5 tanks in one location,reproduce this section and complete for additional tanks.You must read the Instructions(DEENUST-INST-001)in circler to properiy corns plete this Part. Tank No.: "rank No.:- Unk No.: tank No.: Tank No.: = ❑ ❑ ❑ El ❑' ❑ ❑; ❑ CD 13 0 ❑ ❑ ❑ Ci L7 ❑ ❑ o. .3d 7 C1' . ., ❑ ❑ Cl o a a di o: a ❑ .13 o Q o o ❑ o ❑ n ❑ a r d ❑ ❑ a o D ❑ o ❑ a o ❑ ❑ a ❑ _ n a s 13 ❑ ❑ I 1 n ❑ _ DEEP-USTNOT-001 6 of.12 Rev.09/2 fit �rA C D q my � axon 1, WA 31 01, mg €? � ® ■ ■ ® ■ '� ■ ■ ® ■ p c N ® ■ up £gsi � ■ � � �1_{ �q��'�'��'may`��d a`£P& +�-" € �:,� '�s�4i�.al�a� ■ ■ ■ � n � �' a ',�� ���• "i'N Ski f�#y—�°�N$'` s�f��8s ■ ® ® ■ -, ® g. �mmms mwt 1- -Wwv��� KNIMAMMIC19-11"t-Eil MM VO M— gw� al Moll, Alm-, ims 'IN MI 11111 9 all SIR ag NAM QN,R ''I -2-p"'m —!g a'qj—"V. Mw 3h to I - I pi, IN Tlum ............ Mail :Fro WAM 0 t 11 F.it v-111 a ire ow"—111MMOR ................. H .......... 4 , W Milli X'.""I"I'll'' Q ling vd, 01"Z V 111V ME 1: Qm! MIS NIR ey.................. go MR R INA,, WS I M M, WA —N A I 'M m""N. R.4"u on 0 0 m ms Ull I Mr F, PV�"'AMI lg� '.j PartVl'. Certification Of Installation COMPlete.within 30 daysof installingan UST or adding an USTsystem to an existing notification. Ifyou have than 6 tanks in one location, reproduce this part and complete for additional tanks, more Tank No-' 7 Tank No.: Tank No.: Tank Nor, Tank No- - =zr_Q==-� - 0 0 0 0 MWAK-0--ftnu wwwft� 0 0 0' 0 0 0 El 11 0 0 0 0 .0 0. 0 0 Ni Provid at V L n ure o, *r in rtify ProPL StAlliftloh Of'Sublact LIST Systern. 8/13/13 Signa n er Date Jerry Holl Member Nameof. 0 In nt:dr type) We )erry.hollis@harcoservices.com Company Na.me &malf SA -XIC4, Z-347 cAlAt Compa Address Py License Type DEEP-UST-NOT-ooi 11 of 12 Rev.09128/12 Part VII: Owner/Operator Certification The owner/operator and the individual(s).responsible for actually Preparing the notification must'sign this port.A, notification will be considered incomplete unless all re quir0d signatures are pm—videdl 'I.havepersonally exeimirted and am farnili4 With the information submitted In thls�document and all attachrnentsthereto,�arvd I certifythat bapod.on reasons.ble I investigation, including myInquiryofthe individuals responsible for obtainin the information,the submitted information.is true,.accurate and complete to the best of my knowledge and Zef. llundemtand that afalse statement in the submitted information may be.punishable as a crimin ..al offense,in accord nee with section 22a-6 of lheGerloml , a Statutes,pursuant to section:63A-1.57b ofthe General Statutes, and iry accordance With anyother,applicable statute; I certify that I have completed aCerMcafidn.otFinaricial Respoftgibfty Form and sUdh comolatedform is rhaintained on-site. :1 also certify that this underground storage tank notification Is on co mplete and accurate forms asprescribed by the commissioner Withoutafteration ofth*�tq)d.' Signatureof Owner/Oparat.or Bate Name of OwnerlOperator(pritrit ottype) .Sionaturs,*f'Pi;r)ardr Of different than,above) Date Narne-of Ptep.6r*r'(prjnt ortype) W;(if ipplicable) Check,'here if additional signatures are required.Ifso,.please reprodude,this sheet an &6-hsianed copies to thisshea Note; Please submit acomploled Underground.Stbrage,Tank Mfification and all Supporting Docu.me t3to. CENTRAL:PERMIT PROCESSIN G UNIT DEPARTMENT OFENEROY ANDENVIRONMENTAL PROTECTION 79 ELM STREET HARTFORD,CT 06106-5127 A cdpy� 6f 69 comp jeW.Notlocatlon r-orm;mUs be maintained qn.site and themost recent. corq,lol6ted form mu-0 alsobe fcwwarded 16 the.lo�jl fire marshal. If you have any questions,please contact the UST Progre at 660-424-�3,374 or by e7mall (DEEP.UnFe A&ov) -,m DEEP-UST-NOT-001 12,of 1.2 Rev.09/28t12