HomeMy WebLinkAbout140 Rye Street - UST - Fire Marshal 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 I Program: UST
Check the appropriate box(es) identifying the notification type.
1. LOCATION of UST(s)
Name of site: Shepard -Pola, Inca
Street Address or Location Description: 140 Rye St.
City/Town: South Windsor State: CT Zip Code: 06074
2. Site ID Number: #132-10234
No. of Fee *No. of
3. This notification is for: exempt Tanks Total
choose i, ii, iii or iv Fee tanks($0) 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 $100.00/
modifications, (specify modifications under iv tank
below) [#10321
(Complete Parts I and VII and
modifications only)
® 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]
DEEP-UST-NOT-001 1 of 12 Rev.01/02/14
Part I: Notification and Fee Type (continued)
No. of Fee *No. of
exempt Tanks Total
3. (modifications continued) fee tanks($0) excluding (b) Fee=
(a) (b) (c) (a x c)
❑ adding an orphan UST system (newly $100.00/
discovered) (Part IV) tank
[#10321
❑ update/correction to Part 11: $0
owner/operator info/financial responsibility
❑ transfer of ownership (Part 11) $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 1 $0
(Part V)
* Compartmentalized tanks are counted as one tank.
$0
*Manifo/ded or interconnected tanks count as separate tanks *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 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.ct.gov/CONCORD/index.isp)
• 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., Il, Ill, etc.).
1. UST Owner Name: Shepard-Pola, Inc.
This affiliate is the registrant(check if true): Z
Mailing Address: 200 Sullivan Avenue
City/Town: South Windsor State: CT Zip Code: 06074
Business Phone: 860-289-6414 ext.: 227
Contact Person: Kip Shepard Phone: 860-289-6414 ext. 227
*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#:0042188 This information can be accessed at
the Secretary of State's database (CONCORD). (www.coneord-sots.ct.gov/CONCORD/!ndex.usp)
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.gov/CONCORD/index.osp)
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)
5. 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 12t" 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.
Name of Insurer Policy# Surety Type Amount Period of
(insert letter of Coverage
from list Coverage
above or
specify)
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 Identification Number(see instructions) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑
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 ❑ ❑ ❑ ❑ ❑
Date Temporarily Closed
Permanently Closed(check here and skip to Part V) ❑ ❑ ❑ ❑ ❑
2. Date of Installation of Tank(month/year)
3. Life Expectancy of Tank(years)
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) ❑ ❑ ❑ ❑ ❑
Jacketed(Steel with Plastic Jacket) ❑ ❑ ❑ ❑ ❑
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 ❑ ❑ ❑ ❑ ❑
Tank Manufacturer
Check box if tank has ever been repaired ❑ ❑ ❑ ❑ ❑
Complete the following for each compartment or tank.
6. Emergency Generator Use ❑ ❑ ❑ ❑ ❑
7. Estimated Total Capacity(gallons)
Farm Use ❑ ❑ ❑ ❑ ❑
DEEP-UST-NOT-001 6 of 12 Rev.01/02/14
Part IV: Underground Storage Tank Information (continued)
Tank Identification Number(see instructions)
Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑
Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑
8. Substance Currently Stored(or last stored in the case of closed compartments/tanks)
check one per compartmentltank
Gasoline ❑ ❑ ❑ ❑ ❑
Diesel ❑ ❑ ❑ ❑ ❑
Kerosene(for resale) ❑ ❑ ❑ ❑ ❑
Kerosene(on-site consumption) ❑ ❑ ❑ ❑ ❑
Heating Oil(on-site consumption) ❑ ❑ ❑ ❑ ❑
Heating Oil(for resale) ❑ ❑ ❑ ❑ ❑
Used Oil- ❑ ❑ ❑ ❑ ❑
Biodiesel ❑ ❑ ❑ ❑ ❑
E-85 ❑ ❑ ❑ ❑ ❑
E-15 ❑ ❑ ❑ ❑ ❑
If Other,please specify here
Hazardous Substance ❑ ❑ ❑ ❑ ❑
CERCLA name
CAS Number
9. Primary Release Detection -check one per compartment/tank
Annual Precision Tightness Testing ❑ ❑ ❑ ❑ ❑
Tank Tightness Test with inventory Control ❑ ❑ ❑ ❑ ❑
Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑
ATG-CSLD—Continuous with Inventory ❑ ❑ ❑ ❑ ❑
Reconciliation/Control
ATG-Static with Inventory Reconciliation/Control ❑ ❑ ❑ ❑ ❑
Monthly GroundwaterNapor Monitoring ❑ ❑ ❑ ❑ ❑
Manual Tank Gauging ❑ ❑ ❑ ❑ ❑
Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑
No release detection required ❑ ❑ ❑ ❑ ❑
If Other Method, please specify here
DEEP-UST-NOT-001 7 of 12 Rev.01/02/14
Part IV: Underground Storage Tank Information (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 ❑ ❑ ❑ ❑ ❑
Piping Construction
10. Piping Installation Date =
11. Piping Material check one per compartment/tank
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 ❑ ❑ ❑ ❑ ❑
If Other,please specify here
12. Piping—Secondary Containment—check all that apply
Containment Sumps at Dispensers ❑ ❑ ❑ ❑ ❑
Containment Sumps at Tanks ❑ ❑ ❑ ❑ ❑
13. Pipe Fitting check one per compartment4ank
Metallic fitting Isolated from Soil and Water ❑ ❑ ❑ ❑ ❑
Metallic Fitting Cathodically Protected ❑ ❑ ❑ ❑ ❑
14. Construction Type-Piping—check all that apply
Cathodically Protected ❑ ❑ ❑ ❑ ❑
Double Walled ❑ ❑ ❑ ❑ ❑
Metallic Piping Isolated form Soil and Water ❑ ❑ ❑ ❑ ❑
Single Walled ❑ ❑ ❑ ❑ ❑
Unknown ❑ ❑ ❑ ❑ ❑
15. Piping Type-check one per compartment/tank
Pressure ❑ ❑ ❑ ❑ ❑
"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 ❑ ❑ ❑ ❑ ❑
DEEP-UST-NOT-001 8 of 12 Rev.01/02/14
v
Part IV: Underground Storage Tank Information (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 ❑ ❑ ❑ ❑ ❑
16. Primary Release Detection Piping-check one per compartment4ank
Annual Precision Line Tightness Testing ❑ ❑ ❑ ❑ ❑
Precision Line Tightness Testing Every 3 years ❑ ❑ ❑ ❑ ❑
Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑
Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑
GroundwaterNapor Monitoring ❑ ❑ ❑ ❑ ❑
PLLD—Annual.1 gph Leak Test ❑ ❑ ❑ ❑ ❑
PLLD—Monthly Elec.0.2gph Leak Testing ❑ ❑ ❑ ❑ ❑
No release detection required ❑ ❑ ❑ ❑ ❑
If Other Method,please specify here
17. If piping type is pressure-check one per compartment/tank
Electronic Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑
Mechanical Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑
18. Spill and Overfill Protection—check all that apply
Audible Alarm ❑ ❑ ❑ ❑ ❑
Ball Float Device ❑ ❑ ❑ ❑ ❑
Flapper Device ❑ ❑ ❑ ❑ ❑
None ❑ ❑ ❑ ❑ ❑
Spill Prevention Device Installed ❑ ❑ ❑ ❑ ❑
Part V: Permanent Tank Closure
Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
Tank Identification Number SPl
Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑
Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑
1. General Information of Closed Tank
Date of Installation(month/year) 8/1990
Estimated Total Capacity(gallons) 4000
Estimated date tank closed(month/day/year) 6/7/2016
(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.01/02/14
v
a
Part V: Permanent Tank Closure (continued)
Tank Identification Number. Tank No.: Tank No.: Tank No.: Tank No.: Tank No.:
- SPi
Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑
Part of a manifolded or interconnected tankF ❑ ❑ ❑ ❑ ❑
2. Estimated date the UST was last used for 5/5/2016
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 ® ❑ ❑ El
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: —check all that apply
GA PMC ❑ ❑ ❑ ❑ ❑
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 ❑ ❑ ❑ ❑ 1-1
*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).
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.01/02/14
r
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 ❑ ❑ ❑ ❑ ❑
Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑
Installer of tank and piping must check all that apply
Installer certified by tank and piping manufacturers ❑ ❑ ❑ ❑ ❑
Installation inspected by a registered engineer ❑ ❑ ❑ ❑ ❑
Installation inspected and approved by implementing ❑ ❑ ❑ ❑ ❑
agency
Manufacturers 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.
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
w '
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.
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
-t�e commissioner without altera of theleW
i ature n or ate
Kip Shepard p G l� $
Name of Owner/Operator(print 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
(DEEP.USTFee(aD_ct.gov)
DEEP-UST-NOT-001 12 of 12 Rev.01/02/14