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HomeMy WebLinkAbout5 John Fitch Blvd - UST - Fire Marshal (8) i Gt)n�net:tfctit Department,of sneroy', Environmental prof6did, Bureau MatePAIS Menagerrl nt & etrlpliance,Assurai ce i=rn irgl ncy,Respt � & Sp►11 r?�reventjon 6,i,6 o.n Notification for Underground CPUUSEONLY' Storage Tanks 'A p #. 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 1: Notification and Fee Type Frogam.;LIST 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 BLVD City/Town: SOUTH WINDSOR State: CT Zip Code: 06074-4006 2. UST Site ID Number: 132-2271 No,of Fee *.Nti.of 3..' This notification is for: exempt Tanks Total choase f,,ii,iiior•iv Fee excluding(b) Fee= (c) (a x c) ] i) first time site notification [new] $100.00/ (Complete entire application) tank [#10321 ] ii)annual notification [renewal]with NO $100.00/ modifications tank (Complete Parts 1 and VII only) [#10321 iii)annual notification [renewal] with modifications, (specify modifications under $100.00/ iv below) tank (Complete Parts I and VII and [#10321 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 [#10321 0 0 $0 DEEP-UST-NOT-001 1 of 12 Rev.12/18/12 Part I: Notification and Fee Type (continued) y i ✓ � 3 ✓ / Nty of Fee � � *Nst o �' � 3Ec � �✓✓ �"� r✓� - �� ✓ a eXetttpt� � T�utk'" t"� -�0�� {rt�r�ditieatr��s�artiitnued�r �� � Fe � tanks� � �c[� �t�3 Fie � ❑ adding an orphan UST system(newly $100.00/ discovered) (Part IV) tank [#1032] 0 0 $0 ❑ update/correction to Part IL $0 r/ owner/operator info/financial responsibility w ❑ transfer of ownership(Part 11) $01 f ❑ update/correction to Part III: record info $0 r ❑ update/correction to Part IV: UST system $0 info ❑ Permanent Closure of an UST system $0 (Part V) 0 $o *Compartmentalized tanks are counted as©ne tank. x ,� *11%laniolded or in#erconneci`ed tanks corm as separate tanks :. Toiel.Feea,-', $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 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.ciov/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.,II,1/1,etc.). 1. UST Owner 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 *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 Part 11: 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): ❑ 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.jsp) 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: 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 *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 3of 12 Rev.12/18/12 Part I1: Owner/Operator Information (continued) 5. Property Owner, if different than UST owner Name: ALLIANCE ENERGY LLC Mailing Address: 800 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. Class A Operator: must be the individual who was trained. Name: ERIC HARVEY Mailing Address: 15 NE Industrial Rd City/Town: Branford State: CT Zip Code: 06405 Business Phone: (845)238-7354 ext.: E-mail: eharvey@globalp.com Company Name,if applicable: alliance energy Approved Training Course: ECS/Eclipse Connecticut Class A/B Operator Trainin Training Date: 10 Dec 2015 ❑ initial or biennial training OR ❑ retraining ordered for non-compliance Certification Expiration Date: 10 Dec 2017 Class A Operator's Signature: eharvey Signed on:9/9/2016 11:28:17 7. Class B Operator: must be the individual who was trained. Name: ERIC HARVEY Mailing Address: 15 NE Industrial Rd City/Town: Branford State: CT Zip Code: 06405 Business Phone: (845)238-7354 ext.: E-mail: eharvey@globalp.com Company Name, if applicable: alliance energy Approved Training Course:ECS/EClipse Connecticut Class A/B Operator Trainin Training Date: 10 Dec 2015 ❑ initial or biennial training OR ❑ retraining ordered for non-compliance Certification Expiration Date: 10 Dec 2017 Class B Operator's Signature: eharvey Signed on:9/9/2016 11:28:17 DEEP-UST-NOT-001 4 of 12 Rev.12/18/12 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 L Trust Fund B. Commercial Insurance F. eSurety 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 USTs on five or less separate sites. Tokio Marine Specialty Insurance Company PPK1426716 B•Commercial Insurance $2 000,000 1 Dec 2015 1 Dec 2016 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 Iocated.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 be 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-INSTd101) in order to properly complete this Part. ' Tank No.: Tank No.:_ . Tank:No.: Tank.No.: Tank No.: _. Tani€1c)enttflcation Nutla �r�see Instruct o»s) t B-3R1_ B-4R1 B-5R1 K-R1 Pat Wfzazomp en I El El El El — Y - Part of i mAfotded or.► terc snnect4±d�t�k ❑ ❑ ❑ ❑ ❑ tx t. t ' b< d p1 t /terns 1 the Ugh fnr the enter*tank of da not have to cr rrrplete t;e co,urrrns t beled for ctim ati erfrs . < tt ; t. ' Status of Tank' ' Cwrtefitty rn Use ❑✓ ❑✓ ❑✓ ❑✓ El '�Tempvrarflysd ' ❑ ❑ ❑ ❑ ❑ 01 ,. , 'Date TernporarffWosed lgefdat5rt1y Giosed{check here and sktptPart lt} ❑ ❑ ❑ ❑ ❑ Date of"Installation"of Tank(m©nthlyear) 10/01/1988 10/01/1988 10/01/1988 09/01/1997 3 :-`Life Expectan 'of Tank(years)' 30 30 30 30 4. Materiall of Construetlo Tank checkane;aertank' " Asphalt Canted Or Bare Steel. ❑ ❑ ❑ ❑ ❑ Coated and Cathodically Protected Steel(Sfl P3), ❑ ❑ El El El Composite(Steel clad With,Fiberglass) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Plastic.jacket) ❑ ❑ ❑ ❑ ❑ Composite•(Steel with them ne) ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic � ❑ Other(e.g.,concretes etc.) (please specify) 5. . Construction Type-'rank-check all that,apply Lined Interior with Epoxy Coating ❑ ❑ ❑ ❑ ❑ Excavation Liner ❑ ❑ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ] ❑ Single wm!,.6d" 21 RI ❑r ❑ ❑ 'Tank Manufacturer, Cfaeck box if tank has ever been repaired ❑ ❑ ❑ ❑ ❑ ' Complete the tollowing for each.corrtparfrert or tank S Emerigency Generator Us' Only Y . ❑ ❑ ❑ 0 ❑ 7 .EitirnaiedTotaFCapacit�r(galions) 8000 8000 8000 6000 Farm Use ❑ ❑ ❑ ❑ ❑ DEEP-UST-NOT-001 6 of 12 Rev.12/18/12 r ` Part IV: Underground Storage Tank Information (continued) z Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Think IdentHfication ., ber (see instrucYron } Y e B-3R1 B-4R1 B-5R1 B2-R1 T �5`a.�� 1 m y of a copartmeta nl# nk ❑ - El ] ] El1�- o ,.- z, �,,S�°,. •Tim✓��'' 5 R� = ! {// '`"�`Z - - Parf aMfnatlifoided or »terror ected'ihnk ❑ El ] ] El rt �'8 � ���nxrr+�ritiy�tsrrext{g��� st h�ored cn the cas+��of cio,�sed cornphrteoer€tattanks� �� d g ay z I7resel Li ❑ K y r eiosene{far rest U ❑ J ❑ le serve(fin-sr#e eonsuratton ❑ ❑ ] ] ❑ 6410 f�iatrng ❑ ❑ ] ] El o.g Heatrrrg a (for resale) ❑ ❑ ] ] ❑ used Oil ❑ ❑ ] ] ❑ r Siodiesel ❑ ❑ ] ] ❑ ❑ ❑ ] ❑ ❑ sF > -� " U U ] U }. .. If Other, 11, specif here 77777 H'azarcfous Substance ❑ El ❑ ] El GERCLA.name ; GAS Nuitrber 9 Pr'imary Release Detection check one per cornpartrnentltank ,.., Annual Precision Tightness Testing ❑ ❑ ] ] ❑ TankFTightness_Test with Inventory Control ❑ ❑ ] ] ❑ Continuous(Electranrc).Interstitial Monitoring ❑ ❑ ] 21 ❑ ATG= CSLU Continuous with inventory, ❑ ❑ ❑ ❑ ❑ Reconciliation/Control ATG'-Static with Inventory Re conclliationlCon€rol �I U �J —I U monthly Groundwater/va star Monitoring U U U J U Manual Tank,Gauging El El ] ] ❑ Uisval Interstitialalonit�ring ❑ ❑ ] ] El Nn'r�ease'derectrcn`regulrti seertstructctns .' ❑ ❑ ] ] ❑ u g _If C2ther:l�rlethod please-speeify'here: x, DEEP-UST-NOT-001 7 of 12 Rev.12/18/12 Part IV: Underground Storage Tank Information (continued) ZR­ �- Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: T denlification Number B-3R1 B-4R1 B-5R1 B2-R1 � r Y Par#of?t eompntmentaiized tank ❑ ❑ ❑ ❑ ❑ Part rsf a rriariifoide © interconnected tar El El El El ❑ APiping BonStrgc ��� Ys !�5 1 ✓ «�d 10.P#}Sing 1 stallai itin Bate % . 10/01/1988 10/01/1988 10/01/1988 09/01/1997 = r r 11 Ppinf� ateriaf - h$cctnorc©rripartme tank sW111v \AAN'�, El El El El 15 Galvan �d;stl ❑ ❑ ❑ ❑ ❑ m 1�_p Steal ❑ ❑ ❑ ❑ El x yiQrttea ,= ❑ ❑ ❑ ❑ ❑ Y rr ping associated wrth"Tank or Above Ground q#K,H ❑ ❑ ❑ ❑ORR ❑ y Fibert�"loss Reinforced Rlastrc; [l✓ o o ❑✓ ❑ Seim RigdP asti> ,; ❑ ❑ ❑ ❑ ❑ El Othe ❑ ❑ ❑ ❑ ❑ 12 Prping q Secondary Containment check aft at ?tY' r Containment Sirrips at't3tspansers" ❑ ❑ ❑ ❑✓- ❑ Containment Sumps;at Tanks ❑✓ 0 ❑✓ ❑ ❑ 13 "Pipe Fining- check one per compartmendtank" 3vletallic Fitting Isolated from Soil and Water ❑ ❑ ❑ ❑ ❑ Metallic Fitting Cathod]cally Protected, ❑ ❑ ❑ ❑ ❑ 14.Construction Type-Piping check att that appt Cathodically Protected ❑ ❑ ❑ ❑ ❑ Double Wailed ❑ ❑ ❑ ✓❑ ❑ Metallic Piping Isolated form Sol]and Water ❑ ❑ ❑ ❑ ❑ Single Walled; ❑✓ ❑✓ ❑✓ ❑ ❑ Unknown' ❑ ❑ ❑ ❑ ❑ 15.Piping Type-check one per comparimentdtank Pressure r❑ ❑r ❑r ✓❑ ❑ "U.S.'Suction(valve at tank); ❑ ❑ ❑ ❑ ❑ gravity Feed Only', ❑ ❑ ❑ ❑ ❑ `safEA Suction(no naive at tank);', ❑ ❑ ❑ ❑ ❑ Ifd Other,pease specify here<'. Check bok If piping has ever been:;repaired ❑ ❑ ❑ ❑ ❑ DEEP-UST-NOT-001 8 of 12 Rev.12/18/12 Part IV: Underground Storage Tank Information (continued) y Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tahk tdenti ctiors Number B-3R1 B-4R1 B-5R1 B2-R1 Part of ccirmpadmentatitedv Oink ❑ ❑ ❑ ] ❑ l r a.. P of a manitot# d or rntercrn�ne""cted tank ❑ ❑ ❑ . ] ❑ 1ary Ftele # etectiaif F�tpl�All cheek oniyper ratpartmerr k \ ` \` - A inual Pr od s!on Lint,TIg Testing ❑✓ ❑✓ ✓❑ ] ❑ ; b�M "'I P�ecisiori Lind Tightness Tr?slifi yew years ❑ ❑ ❑ ] ❑ i ContintWO dl€ecctrortic)niter ft €tvtonftonn El El El ] ❑ yul}snthly+Csual �e tatfatMonitottng U Li Li ] U Cro t rNapor AAortittsrtltg" U U U ] U ill Lb(' Annual igph Leek Test ❑ ❑ ❑ ] ❑ PI LII Mo tt y Etec.0 2gph Ike �c Te`stir 9 ❑ El El ] El Nr�r toase poprewired{see fi) trwctlons) ❑ ❑ ❑ ] ❑ Yt . Method, Ieaeeepecify Here., 17 I#piping Type Is pressure=checJrtsrre per catrtpartmeittJtank EiectroticAutoLinet�ak-Detectors.: ❑ ] OJ ~ Mechanical Auto. me t eak,Detectors; U U U J U 18 Spill and Overfill Protection cJl�ck atJ that apply Addible Alarm, iD (] [] Ball Pioat Device ❑ ❑ ❑ ] ❑ ti - ✓ ✓.__ Flapper Device I � ] ❑ � ❑ F. None ❑ ❑ ❑ ] ❑ Spill Prevention Device Installed ✓j J U 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 a manifolded or interconnected tank ❑ ❑ ] ❑ ❑ 1. General Information of Closed Tank bate'of installation(inorithlyear) Estim, ed,Total Capacity(gallons) Estimated date tank:close f(montli`Idaj, ear) check one per tank). Tank was removed frpM ground ❑ ❑ ] ❑ ❑ Tattk was closed:m grounri ❑ ❑ ] ❑ ❑ Tanl lilted with merit material U U J U U Describe the1nert fill material here DEEP-UST-NOT-001 9 of 12 Rev.12/18112 Part V: Permanent Tank Closure (continued) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: ;Tank kien#fft t}on hFumtxeY P of a compact tat}zed tanC� ❑ ❑ ❑ ❑ ❑ zM Part ❑ ❑ ❑ ❑ ❑ 2 Estitnatot date the List' ( st sfse fflr r stat�regttated7171 s-b antes ttnotte Jsseasr»ent ' ems„ y y unit srfEAumplEtE� ❑ ❑ ❑ ❑ ❑ _ ikf_�es grotfde`j tgu}tarttteentrg i `atlonbet" 1� t �/ �� Cott.�nt/ContrrlGttl���`&fnE4s�. r CoAsu}tanUCnntCdG�r Adrtesses(s3 Consia}faglCuifftaetor Pbotfes - , SoU Saingtes Comas d and klnafyzE}for one m ore of the fo#ewiw� %UUCs."SY{1Cs Meta s ETPFfi El El ❑ El El" -_ . Groundwater 'rICb1213terEd tkrrfng Assessmt nt ❑ ❑ ❑ ❑ ❑ Groundwater camp}es collected and MAMA,for one or El El El El Elmore of the following;;UCCs SUt1Cs Ivtetafs,ETP14 Sal SarnpYes bad Gonsntuenis of Condern above"the foftow}rig RSRritena check all fist apply GAPMC• ❑ ❑ ❑ ❑ ❑ GB PMC- ❑ ❑ ❑ ❑ ❑ Res DEC,; ❑ ❑ ❑ ❑ ❑ .i/C DEC ❑ ❑ ❑ ❑ ❑ 'If any boxes,were checked above,include i.table summanziiig the data and highlghting the exceedances iSee R.0 S-A.Sections 22a 133k-1 through 3 for definitions). *Groundwater.Sainiiies had Constituents of Concern above"wing RSR,Cr}feria: - check all that apply, G1AtPC El El ❑ ❑ ❑ S1NPC - ❑ ❑ i❑ ❑ ❑ Res GWVC ❑ ❑ ❑ ❑ ❑ I/C GVWC ❑ ❑ ❑ ❑ ❑ #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 tot definitions). Remedial Actions Recommended by Environmental Ctrsuitant/Contracior ❑ ❑ ❑ ❑ ❑ If box is checked,<A closure repot must tie submitted to the t t35T Coordination Progtatn for evaluation. Remedial Actions Completed it box is checked,a closure report must be submitted to the ❑ ❑ ❑ ❑ ❑ t UST Coordination Program fi t evaluation. ' DEEP-UST-NOT-001 10 of 12 Rev.12/18/12 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.: Ga � � a�� , ,Tank'I afi rca#its truer, lnstler # ratWw''r�p�pif �� I»staEtcr c it ed try tank a cf ptpcng mari f ct ra =' ] ❑ ] ❑ ❑ $ Ins#atlattcrni tsy a registered engineer J U J J ❑ y� stallaott Inspected and approved by implementing ❑ —I J LJ agency' Nlanutrer 5�ttslltrrt ccktfs t1r aen;'` ❑ ❑ ] ] ❑ NPp c0plefied'„. 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 VII: Owner/Operator Certification The owner/operatorand 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 1 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. I 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." Signed on:9/15/2016 9:29:50 AM 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 (DEEP.USTFeena ct_aov) DEEP-UST-NOT-001 12 of 12 Rev.12118/12