HomeMy WebLinkAbout1540 Sullivan Avenue - UST - Fire Marsha ConnecOwt,Department of
Energy.& Environmental Protect tin
Bureau of Materials Managem.nt & Compliance Assurance
Emergency Response &_Spill Prevention Division
Notification for Underground
Storage Tanks
Please complete this form, in accordance with the instructions
(DEEP-UST-INST-001)to ensure the proper handling of your
notification. Print or type unless otherwise noted.
Submit one notification form per site.
Para I: Notification and Fee Type
Check the appropriate box(es) identifying the notification type.
1. LOCATION of UST(s)
Name of site: Town of South Windsor-Town Hall
Street Address or Location Description: 1640 Sullivan Avenue
City/Town: South Windsor State: CT Zip Code: 06074
2. Site ID Number: 132-2302
❑ i) first time site notification $100.00/
(Complete entire application) tank
❑ ii) annual notification with NO $100.00/
modifications tank
(Complete Parts I and VII only)
❑ iii) annual notification with $100.00/
modifications, (specify modifications under iv tank
below)
(Complete Parts I and VII and
modifications only)
® iv) a to an existing notification; check any of the following to specify.
(Complete Parts I and VII only)
❑ adding new UST system (Part IV) $100.00/
tank
DEEP-UST-NOT-001 1 of 12 Rev.01/02/14
a /
Part I: Notification and Fee Type (continued)
❑ adding an orphan UST system (newly $100.00/
discovered) (Part IV) tank
❑ update/correction to Part II: $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) 1 0
0
*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 a
statutory trust,it must be registered with the Secretary of State. If applicable, the applicant's 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.et.aov/CONCORD/index.osp)
• 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., ll, lll, etc.).
1. UST Owner Name:
This affiliate is the registrant(check if true): ❑
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Contact Person: Phone: ext.
*E-mail:
*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 2 of 12 Rev.01/02/14
Part II: Owner/Operator Information
a) Business Type (check one):
❑ 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#: 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, if different than UST owner
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Contact Person: Phone: ext.
*E-mail:
a) Business Type (check one):
❑ 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#: This information can be accessed at the
Secretary of State's database(CONCORD). (www.concord-sots.ct.aov/CONCORD/index isa)
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.
❑ Check if any co-owners/operators. If so, attach additional sheet(s)with the required information as requested above.
3. Billing contact, if different than UST owner or operator
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Contact Person: Phone: ext.
E-mail:
4. Primary contact, if different than UST owner
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Contact Person: Phone: ext.
*E-mail:
*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.01/02/14
Part II: Owner/Operator Information (continued)
6. Property Owner, if different than UST owner
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Contact Person: Phone: ext.
E-mail:
6. Class A Operator: must be the individual who was trained.
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
E-mail:
Company Name, if applicable:
Approved Training Course:
Training Date: ❑ initial or biennial training
OR
❑ retraining ordered for non-compliance
Certification Expiration Date:
Class A Operator's Signature:
7. Class B Operator: must be the individual who was trained.
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
E-mail:
Company Name, if applicable:
Approved Training Course:
Training Date: ❑ initial or biennial training
OR
❑ retraining ordered for non-compliance
Certification Expiration Date:
Class B Operator's Signature:
DEEP-UST-NOT-001 4 of 12 Rev.01/02/14
Part II: 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 12th 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 USTs on five or less separate sites.
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 ❑ No
If yes, provide the central location address below.
Name of Location:
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 be kept at a centralized location or that must be kept on site.
DEEP-UST-NOT-001 5 of 12 Rev.01/02/14
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.:Al R1 Tank No.: Tank No.: Tank No.: Tank No.:
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DEEP-UST-NOT-001 6 of 12 Rev.01/02/14
Part IV: Underground Storage Tank Information (continued)
Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
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DEEP-UST-NOT-001 7 of 12 Rev,01/02/14
Part IV: Underground Storage Tank Information (continued)
Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
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DEEP-UST-NOT-001 8 of 12 Rev.01/02/14
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Part V: Permanent Tank Closure (continued)
Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Al R1
❑ ❑ ❑ ❑ ❑
7/17/14
® ❑ ❑ ❑ ❑
Fuss&O'Neill,Inc.
146 Hartford Road
Manchester,CT 06040
860-646-2459
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DEEP-UST-NOT-001 10 of 12 Rev.01/02/14
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.:
❑ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
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Provide signature of UST Installer to certify proper installation of subject UST System.
Company Name:
License Type:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Name of UST Installer: Title:
E-mail: Phone: ext.:
Signature of UST Installer Date
DEEP-UST-NOT-001 11 of 12 Rev.01/02/14
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.:
❑ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
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Provide signature of UST Installer to certify proper installation of subject UST System.
Company Name:
License Type:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Name of UST Installer: Title:
E-mail: Phone: ext.:
Signature of UST Installer Date
DEEP-UST-NOT-001 11 of 12 Rev.01/02/14
Part V11: 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 and belief. information is true,accurate and complete to the best of my knowledge
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-167b of the General Statutes, and
in accordance with any other applicable statute.
I certify that,I have completed a Certification of Financial Responsibility Form and such completed form is
maintained on-site.
i also certify that this underground storage tank notification is on complete and accurate forms as prescribed by the
commissioner without alteration of the text."
ors
Signature of Ownerloperator Date
Matthew B. Galligan
Town Manager
Town of South Windsor
Name of Owner/Operator(print or type). Title(if applicable)
f
8 ZoIq
Signat Preparer(if different than above) Date
Russell T.Ward P.E. Sr. Environmental Engineer,Fuss&O'Neill Inc.
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, CT06106-6f27
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
(DEEP.USTFee0-ct.gov)
DEEP-UST NOT 001A 1 of 2 Rev.01102/14