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Home My WebLink About5 John Fitch Blvd - UST - Fire Marshal (4) Connecticut Department of Energy & Environmental Protection Bureau of Materials Management &Compliance Assurance Emergency Response & Spill Prevention Division Notification for Underground CPPU USE ONLY Storage Tanks App#: Please complete this form,in accordance with the instructions Doc#: (DEEP-UST-INST-001)to ensure the proper handling of your notification. Print or type unless otherwise noted. Check#: Submit one notification form per site. Part I: Notification and Fee Type Program: UST 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'B'LVD City/Town: SOUTH WINDSOR State: CT Zip'Code: 06074-4006 2. 'UST Site ID Number: 132-2271 No.of Fee *No.of 3. This notification is for: exempt Tanks Total choosei, ii, iiioriv Fee excluding(b) Fee (a) (b) (c) (a x c) ❑ i) first time site notification [new] $100.00/ (Complete entire application) tank [#1032] ❑ ii)annual notification[renewal]with NO $100.00/ modifications tank (Complete Parts I and VII only) [#1032] ❑✓ iii)annual notification[renewal] with modifications, (specify modifications under $100.00/ iv below) tank (Complete Parts'I and VII and [#1032] modifications only) 0 4 $400 ❑✓ iv) a modification to an existing notification;check any of the following to specify. (Complete Parts I and VII and modifications only) ❑ adding new UST system(Part IV) $100.00/ tank [#1032] 0 0 $0 DEEP-UST-NOT-001 1of 12 Rev.12/18/12 Part I: Notification and Fee Type (continued) No.of Fee *No:of exempt Tanks Total 3. (modifications continued) -Fee tanks($0) excluding(b)l Fee,= adding an orphan UST system(newly $100.00/ discovered) (Part IV) tank [#1032] 0 0 $0 ❑ update/correction to Part 11: $0 owner/operator info/financial responsibility ❑ transfer of ownership(Part II) $0 ❑ update/correction to Part"III: record info $0 ❑ update/correction to Part IV: UST system $0 info Permanent Closure of an UST system $0 (Part V) 0 $0 *Compartmentalized tanks are counted as one tank. *Manifo/ded or interconnected tanks count as separate tanks *Total Fee: $400 *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 Energy and Environmental'Protection. Part II: Owner/Operator Information *If an Owner/Operator is a corporation,limited liability company,limited,partnership,limited liability partnership,or statutory trust,it must be registered with the Secretary of State.If applicable,the applicants name shall be stated exactly as it is registered with the Secretary of State.Please note,for those entities registered with the Secretary of State,the registered name will be the name used by DEEP. This information can be accessed at the Secretary of State's database (CONCORD). (www.concord-sots.ct.gov/CONCORD/index.jsp) If an Owner/Operator is an individual,provide the legal name(include suffix)in the following format:First Name;Middle Initial,Last Name;Suffix(Jr,Sr.,11,1//,etc.). 1. UST Owner Name: GLOBAL MONTELLO GROUP CORP. This affiliate is the registrant(check if true): Mailing Address: 800 South St-suite Soo City/Town: Waltham State: MA Zip Code: 02453 Business Phone: (781)674-7780 ext.: Contact Person: DAVID WENT Phone: ext. *E-mail: Dwent@allianceenergy.com *By providing this e-mail address you are agreeing to receive official correspondence from the department,at this electronic address,concerning the subject application.Please remember to check your security settings to be sure you can receive a-mails from"ct.gov"addresses.Also,please notify the department if your e-mail address changes' a) Business Type(check one): ❑ individual ❑ federal agency ❑ state agency ❑ municipality ❑ **tribal ❑✓ *business entity(*If a business entity complete i through ii): DEEP-UST-NOT-001 2 of 12 Rev.12/18/12 t Part II: Owner/Operator Information i) provide Secretary of the State business ID#: 0841321 This information can be accessed at the Secretary of State's database,(CONCORD),(www.concord-sots.ct.gov/CONCORD/index.isp ii) ❑ Check here if your business is NOT registered with the Secretary of State's office. **Notification or fee is NOT required for UST systems located on tribal lands. 2. 'UST Operator Name: GLOBAL MONTELLO GROUP CORP. This affiliate is the registrant(check if true): ❑ Mailing Address: 800 South St-suite 500 City/Town: Waltham State: MA Zip Code: 02453 Business Phone: (781)674-7780 ext.: Contact Person: DAVID WENT Phone: ext. *E-mail: Dwent@allianceenergy.com a) Business Type(check one): El individual ❑ federal agency ❑ state agency ❑ municipality ❑ **tribal ❑✓ *business entity(*If a business entity complete i through ii): i) provide Secretary of the State business ID#: 0841321 This information can be accessed at the Secretary of State's database(CONCORD).(www.concord-sots.ct.gov/CONCORD/index.isp) ii) ❑ Check here if your business is NOTregistered with the Secretary of State's office. **Notification or fee is NOT required for UST systems located on tribal lands. ❑ Check if any co-owners/operators.If so,attach additional sheet(s)with the required information as requested above. 3. Billing contact Name: GLOBAL MONTELLO GROUP CORP. Mailing Address: 705-A Lakeview Plaza Blvd City/Town: Worthington State: off Zip Code: 43085 Business Phone: (614)433-0170 ext.: Contact Person: MEGAN KAZMIERCZAK Phone: (614)433-0170 ext. E-mail: MKAZMIERCZAK@ECSECLIPSE;COM 4. Primary contact, if different than UST owner Name: GLOBAL MONTELLO GROUP CORP. Mailing Address: Boo South St-Suite 500 City/Town: Waltham State: MA Zip Code: 02453 Business Phone: (781)674-7780 em,. Contact Person: DAVID WENT Phone: ext. *E-mail: 'Dwent@allianceenergy.com *By providing this e-mail address you are agreeing to receive official correspondence from the department,at this electronic address,concerning the subject application.Please remember to check your security settings to be sure you can receive a-mails from"ct.gov"addresses.Also,please notify the department if your e-mail address changes. DEEP-UST-NOT-001 3 of 12 Rev.12/18/12 Part 1'I: Owner/Operator Information (continued) 5. Property Owner, if different than UST owner Name: ALLIANCE ENERGY LLC Mailing Address: Boo South St-Suite 500 City/Town:Waltham State: MA Zip Code: 02453 Business Phone: (781)674-7780 ext.: Contact Person: DAVID J.WENT Phone: (781)402-8893 ext. E-mail: dwent@allianceenergy.com 6. Glass A Operator: must be the individual who was trained. Name: STEPHANIE VENUTO Mailing Address: 800 South St-Suite 500 City/Town: Waltham State: MA Zip Code: 02453 Business Phone: (781)674-7780 ext.: E-mail: svenuto@allianceenergy.com Company Name, if applicable: alliance energy Approved Training Course: ECS/Eclipse Connecticut Class A/B Operator Training Training Date: 13 Aug 2014 ❑✓ initial or biennial training OR El retraining ordered for non-compliance Certification'Expiration Date: 13 Aug 2016 Class A Operator's Signature: svenuto Signed on:9/4/2014 10:37:16 7. Class B Operator: must be the individual who was trained. Name: STEPHANIE VENUTO Mailing Address: 800 South St-Suite 500 City/Town: Waltham State: MA Zip Code: 02453 Business Phone: (781) 74-7780 ext.: E-mail: svenuto@allianceenergy.com Company Name,if applicable: alliance energy Approved Training Course:ECS/Eclipse Connecticut Class A/B Operator Training Training Date: 13 Aug 2014 ❑✓ initial or biennial training OR ❑ retraining ordered for non-compliance Certification Expiration Date: 13 Aug 2016 Class B Operator's Signature: SVenuto Signed on:9/4/2014 10:37:16 DEEP-UST-:NOT-001 4 of 12 Rev.12/18/12 Part'I'1: Owner/Operator Information (continued) 8. Financial Mechanism(s):Complete the table below identifying the financial assurance mechanism(s)used to demonstrate financial responsibility as 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 E. Guarantee I. Trust Fund B. Commercial Insurance F. Surety Bond J. *State Fund C. Risk Retention Group G. Letter of Credit K. Other Method(specify in D. Local Government H. Bond Rating Test table below) Financial Test *Pursuant to section 262 of Public Act 12-1 of the June 12"Special Session,the state fund(UST Petroleum Clean-Up Program)will cease to serve as a financial responsibility mechanism on: October 1,2012,for those who own or operate USTs on more than five separate sites;and October 1,2013 for municipalities and for those who own or operate LISTS on five or less separate sites. LIBERTY SURPLUS INSURANCE CORPORATION TXE-HO-105584-113 B.Commercial Insurance $2 000,000 5 Dec 2013 1 Dec 2014 Owners/Operators shall complete the attached"Certification of Financial Responsibility Form"and maintain such completed form at the facility where the storage tank system(s)are located.THIS FORM DOES NOT NEED TO BE SUBMITTED but must be updated to reflect any changes. Part III: Record Information Off-Site Storage of Records at a Centralized Location Does the owner/operator of more than 10 facilities with UST systems request to store certain records at a centralized location? ❑ Yes (Leave unchecked if'No') If yes, provide the central location address below. Address: City/Town: State: Zip Code: 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 storage tank system records that may kept at a centralized location or that must be kept on site. DEEP-UST-:NOT-001 5 of 12 Rev.12/18/12 Part IV: Underground Storage Tank Information Complete for all tanks and piping at the subject location. 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 (DEEP-UST-INST-001)in order to properly complete this Part. Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number(see instructions) g-3R1 B-4R1 B-5R1 B2-R1 Part of a compartmentalized tank ` ❑ ❑ ❑ ❑ El Part of a manifolded or interconnected tank ` ❑ ❑ ❑ ❑ ❑ Complete items 1 through 5 for the entire tank-you do not have to complete the columns labeled for compartments. 1. Status of Tank Currently in Use ❑ Temporarily Closed ❑ ❑ ❑ ❑ El Date Temporarily Closed Permanently Closed(check here and skip to Part V9 ❑ ❑ ❑ ❑ ❑ 2. Date of Installation of Tank(month/year) 10/01/1988 10/01/1988 10/01/1988 09/01/1997 3. Life Expectancy of Tank(years) 30 30 30 30 4. Material of Construction-Tank-check one per tank Asphalt Coated or Bare Steel ❑ ❑ ❑ ❑ ❑ Coated and Cathodically Protected Steel(STI-P3) ❑ ❑ ❑ ❑ ❑ Composite (Steel clad with Fiberglass) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Plastic Jacket) ❑ El ❑ ❑ ❑ Composite(Steel with Urethane) ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ Other(e.g., concrete, etc.) (please specify) 5. Construction Type—Tank—check all that apply Lined Interior with Epoxy Coating ❑ ❑ ❑ ❑ ❑ Excavation Liner ❑ ❑ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑✓ ❑ Single Walled ❑✓ ❑o ❑ ❑ Tank Manufacturer` Check box if tank has ever been repaired ❑ ❑ El ❑ - ❑ Complete the following for each compartment or tank. 6. Emergency Generator Use Only ❑ ❑ ❑ ❑ ❑ 7. Estimated Total Capacity(gallons) 8000 8000 8000 6000 Farm Use ❑ ❑ ❑ ❑ El DEEP-UST-NOT-001 6 of 12 Rev.12/18/12 Part IV: Underground Storage Tank Information (continued) Tank Identification Number (see instructions) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: B-3'R1 B-4R1 B-5R1 B2-R1 Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ 8. Substance Currently Stored(or last stored in the case of closed compartmentsitanks) check one pet compartmentltank Gasoline ❑✓ ❑✓ ❑ ❑ ❑ Diesel ❑ ❑ ❑✓ ❑ ❑ Kerosene(for resale) ❑ ❑ ❑ 121 ❑ Kerosene (on-site consumption) ❑ ❑ ❑ ❑ ❑ Heating Oil(on-site consumption) ❑ ❑ ❑ ❑ 11 m Heating Oil(for resale) ❑ ❑ ❑ ❑ ❑ Used Oil ❑ ❑ ❑ ❑ El Biodesel ❑ ❑ ❑ ❑ ❑ E-85 ❑ ❑ ❑ ❑ ❑ E-15 ❑ ❑ ❑ ❑ ❑ If Other,please specify here Hazardous Substance ❑ ❑ ❑ ❑ ❑ CERCLA name CAS Number 9. Primary Release Detection-check one per compartmentltank Annual Precision Tightness Testing ❑ ❑ ❑ ❑ ❑ Tank Tightness Test with Inventory Control ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring , ❑ ❑ ❑ ❑2 ❑ ATG-CSLD-Continuous with Inventory ❑ El ❑ ❑ El ATG-Static with Inventory Reconciliation/Control ' ❑✓ ❑� ❑ ❑ Monthly Groundwater/Vapor Monitoring ❑ ❑ ❑ ❑ ❑ Manual Tank Gauging ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method, please specify here DEEP-UST-NOT-001 7 of 12 Rev.12/18112 Part IV: Underground Storage Tank Information (continued) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number B-3R1 s-4R1 a-5R1 a2-R1 Part of compartmentalized tank ❑ ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ El Piping Construction 10.Piping Installation Date 10/01/1988 10/01/1988 10/01/1988 09/01/1997 11. Piping Material - :check one per compartmen tank Bare Steel ❑ ❑ ❑ ❑ El Galvanized Steel ❑ ❑ ❑ ❑ ❑ Epoxy Coated Steel ❑ ❑ ❑ ❑ ❑ Flexible Plastic ❑ ❑ ❑ ❑� ❑ No Piping associated with Tank or Above Ground Only ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑� ❑ ❑ Semi-Rigid Plastic` ❑ ❑ ❑ ❑ ❑ Copper ❑ ❑ ❑ ❑ ❑ Other ❑ ❑ ❑ ❑ ❑ 12.Piping—Secondary Containment— check all t at apply Containment Sumps at Dispensers ❑ ❑ ❑ ❑ ❑ Containment Sumps at Tanks: ❑✓ ❑✓ ❑ 13. Pipe Fitting- check one per compartment/tank Metallic Fitting Isolated from Soil and Water ❑ ❑ ❑ ❑ ❑ Metallic Fitting Cathodically Protected ❑ ❑ ❑ ❑ ❑ 14.Construction Type-Piping— check all that appl Cathodically Protected ❑ ❑ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑✓ El Metallic Piping Isolated form Soil and Water ❑ ❑ ❑ ❑ ❑ Single Walled Z ❑✓ ❑✓ ❑ ❑ Unknown ❑ ❑ ❑ ❑ ❑ 15.Piping Type-check one per compartmentltank Pressure Z ❑✓ ❑d ❑ "U.S."Suction(valve at tank) ❑ ❑ ❑ ❑ ❑ Gravity Feed Only ❑ ❑ ❑ ❑ ❑ "Safe"Suction(no valve at tank)': ❑ ❑ ❑ ❑ ❑ If Other,please specify here Check box if piping has ever been repaired ❑ ❑ ❑ ❑ El DEEP-UST-NOT-001 8 of 12 Rev.12118112 Part IV: Underground Storage Tank Information (continued) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number;, B-3R1 B-4R1 B-5R1 B2-R1 Part of'a compartmentalized tank ❑ ❑ ❑ ❑ El Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ 16.Primary Release Detection-Piping- check one per compartment/tank Annual Precision Line Tightness Testing ❑� ❑� 0El Precision Line Tightness Testing Every 3 years ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Monthly Visual interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Groundwater/Vapor Monitoring, ❑ ❑ ❑ ❑ ❑ PLLD-Annual Agph,Leak Test ❑ ❑ ❑ ❑ PLLD-Monthly Elea 0.2gph Leak Testing; ❑ ❑ ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method,please specify here 17.If piping type is pressure-`check one per compartmentltank Electronic Auto Line Leak DetectorsF ❑ ❑ ❑ El Mechanical Auto Line Leak Detectors` ❑ 18.Spill and Overfill Protection- check all that apply Audible Alarm ❑ ❑ ❑ ❑ ❑ Ball Float Device ❑ ❑ ❑ ❑ ❑ Flapper Device 0 O (] ❑ None ❑ ❑ ❑ ❑ ❑ Spill Prevention Device Installed O - O ❑ Part V: Permanent Tank Closure Tank Identification Number' Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Part of amanifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ 1. General Information of Closed Tank Date of Installation(monthlyear) Estimated Total Capacity(gallons) 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` DEEP-UST-NOT-001 9 of 12 Rev.12/18/12 Part V: Permanent Tank Closure (continued) Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ 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(;) Soil Samples Collected and Analyzed for one or more of ❑ El ❑ El El 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: — check all that apply GAPMC ❑ ❑ ❑ ❑ GB PMC ❑ ❑ ❑ ❑ ❑ Res DEC ❑ ❑ ❑ ❑ ❑ I/C DEC ❑ ❑ ❑ ❑ ❑ *If any boxes were checked above,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: — check all that apply GWPC' ❑ ❑ ❑ ❑ ❑ SWPC ❑ ❑ ❑ ❑ ❑ Res GWVC ❑ ❑ ❑ ❑ ❑ I/C GWVC ❑ ❑ ❑ ❑ ❑ *If any boxes were checked above,include a table summarizing the data and highlighting the exceedances=(See R.CS.A.Sections 22a 133k-1 through 3 for definitions). _ Remedial Actions Recommended by Environmental Consultant/Contractor ❑ ❑ ❑ ❑ ❑ If box is checked,a closure report must be submitted to the 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.' DEEP-UST-NOT-001 10 of 12 Rev.12118/12 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 No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification'Number Pa rt of a compartmentalized Tank ' ❑ ❑ ❑ 0 El Installer of tank and i in must check all that 1 I' as P P J _ pPY-_, Installer certified by tank and piping manufacturers ❑ ❑ ❑ ❑ ❑ Installation inspected b a registered engineer p Y g- ❑ ❑ ❑9 ❑ El Installation inspected and approved by implementing ❑ ❑ ❑ ❑ El agency, Manufacturer's installation checklists have been " El El El Elcompleted El If Other Method, please specify here' Provide signature of'UST Installer to certify proper installation of subject UST System. Company Name: License Type: Company Address: City/Town: State: Zip Code: Business Phone: ext.: Name of UST Installer (print or type): Title: E-mail: Phone: ext.: Signature and Date of UST Installer: DEEP-UST-NOT-001 11 of 12 Rev.12/18/12 Part VI'I: Owner/Operator Certification The owner/ope rato rand 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. 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. certify that I have completed a Certification of Financial Responsibility Form and such completed form is maintained on-site. also certify that this underground storage tank notification is on complete and accurate forms as prescribed by the commissioner without alteration of the text." Signature of Owner/Operator Date Name of Owner/Operator(print or type) Title (if applicable) Signature of Preparer(if different than above) Date 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 ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM STREET HARTFORD, CT 06106-5127 A copy of all completed Notification Forms must be maintained on site and the most recent completed 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 (DE'EP.USTFeeCabct.aov) DEEP-UST-NOT-001 12 of 12 Rev.12/18/12