HomeMy WebLinkAbout1175 ELLINGTON RD ------�- APPLICATION FOR ELECTRICAL PERMIT
DEPARTMENT DECISION TOWN OF SOUTH WINDSOR PERMIT#
Application is hereby: BUILDING DEPARTMENT l b 0 0-7`:z
APPR VE 1540 SULLIVAN AVENUE
} ) �, 644-2511 ext. 230 Bldg. Permit#
Date Building Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
$0-$1,000=$15.00 ���� L." �s I
Over$1,000= Streef No. Street Lot No.
$15.00 per$1,000
or any fraction thereof Tenant Designation Apt. No.
APPLICANT Ci emu.
APPLICANT ADDRESS
APPLICANT'S PHONE # c�
OWNER -" e
�0W N St OWNER ADDRESS
OWNER PHONE
ESTIMATED COST$
IS THIS A CONTRACT COST? Yes -- e
FEE ENCLOSED $
TYPE OF JOB:
SO R•CON New Installation
Alteration/Addition/ Repair p20����3uC
Revised 03/05/10
APPLICATION FOR ELECTRICAL PERMIT(Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? ❑ YES ❑ NO
❑ RESIDENTIAL CURRENT USE AND OCCUPANCY
❑ BUSINESS
❑ ASSEMBLY FUTURE USE AND OCCUPANCY
❑ EDUCATIONAL
❑ INSTITUTIONAL ENGINEER'S NAME PHONE
❑ FACTORY
❑ STORAGE ADDRESS
O GARAGE
O MIXED USE CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATION/WIRING METHOD
SIZE OF SERVICE SIZE OF MAIN CONDUCTORS
NUMBERS OF METERS NUMBERS OF DISCONNECTS AND RATINGS
NUMBERS OF PANELS NUMBERS OF DISCONNECTS REQUIRED? O YES ❑ NO
NUMBERS OF LIGHT CIRCUITS NUMBER OF POWER CIRCUITS
NUMBER OF SWITCHES NUMBER OF OUTLETS
NUMBER OF LIGHT FIXTURES NUMBER OF HEAT CIRCUITS
NUMBER OF A/C CIRCUITS
SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED.
DESCRIPTION OF WORK
THE UNDERSIGNED HEARBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE PERFOR-
MANCE OF SUCH WORK
CONTRACTORS LICENSE NO. STATE
SIGNATURE OF APPLICANT DATE
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/28/22,3:04 PM Print Map
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MAP DISCLAIMER -NOTICE OF LIABILITY Approximate Scale: 1 inch=50 feet
This map is for assessment purposes only.It is not for legal description W E
or conveyances.All information is subject to verification by any user. 0 SO
The Town of South Windsor and its mapping contractors assume no
legal responsibility for the information contained herein. Feet S
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UNITED
INDUSTRIAL
SERVICES, INC.
DIMON OF UNITED OIL RECOVERY.PC.
136 GRACEY AVENUE
MERIDEN,CT 06450
(203)235-3753
To Whom It May Concern:
Enclosed is completed COPY 3 of the UNIFORM HAZARDOUS WASTE MANIFEST regarding
waste received at our facility on y o2`f^�76
COPY 3 and your COPY 8 of the manifest must be retained in your files.
All waste received at our facility is analyzed, categorized and treated on site.
All hazardous waste residue from our treatment process is incinerated at licensed
facilities.
The following outlines our treatment methods:
1. S02 Tank Storage
2. T46 Ultrafiltration
3. T62 Reverse Osmosis
4. T49 Carbon Filtration
5. T50 Blending
6. R03 Incineration for Thermal Value On Site (Industrial Boiler)
7. R16 Incineration for Thermal Value Off Site (Cement Kiln)
The State of Connecticut taxes all hazardous waste received in this state. You may
be exempt and can contact the State of Connecticut, Department of Revenue if you
have any questions regarding this tax.
Very truly urs, 1
"'Z2�e—
David J. Carabetta
President
DJC/js
Enclosure
li
EPHM-
I „9e IKV;
IK, STATE OF CONNECTICUT
DEPARTMENT OF ENVIRONMENTAL PROTECTION
0 Hazardous Waste MANIFES'C PROGRAM
79 Elm St.,Hartford,CT 06106-5127
Please type(or print) (Form designed lot use on elite I 12-Latch)typewrirev,; FOR STATE USE ONLY
UNIFORM HAZARDOUS 1.Generator's US EPA ID No Manifest 2 Page 1 Inlormauon in the snaded areas is
WASTE MANIFEST .�,t.I 9orulnpnl . .� of required by Federal law u may
i (•(n5, required by State law
3 Generator's Name rid Mathn ddress A.State Manifest Document Number
�. ��^ sor i,c �fY� -T CT F 0533637
t r r4 OIL-
B G.S.I. !Gen. Site Address) A
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0 4 Generator's Phone
v 5 Transporter 1 Company" US EPA ID Number
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a 7 Transporter 2 Company Name 8 US EPA ID Number C.S.T 1, (Trans Lic Plate a) f D
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9 Designated Fa Irtyo�me nd S I Address 10. US EPA ID Number E. S.T.I. (Trans Lic. Plate k)
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u ---36 6!-rt.t<y AV,- G. State Facility's ID(Not Required) Q
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12 Containers 13 14 I M
u 11. US DOT Description(Including Proper Shipping Name. Hazard Class, and ID Number) Total unit
No Type Ouantity WtNo+ Waste No
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0 15 Special Handling Instructions and Additional Information
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C Point of Departure:
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rr 16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by
proper shipping name and are classified,packed,marked,and labeled, and are in all respects in proper condition for transport by highway
w according to applicable international and national government regulations.and all applicable Slate laws and regulations. p
Z If I am a large quantity generator.I certify that I have a program in place to reduce the Volume and toxicity of waste generated to the degree I have determined to be ` f
u.
economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present �_Y}
w and future threat to human health and the environment,OR,if I am a small quantity generator,I have made a good faith e`iort to minimize my waste generation and
Z select the best waste management method that is available to me and that I can afford. 1
u PrinledlTyped Name S gnature n t Month Day Year
Im
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z T 17, Transporter 1 Acknowledgement of Receipt of Materials Cn
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a A Printed/Typed Name 1 Signatur Month Day vear w
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~ 0 18. Transporter 2 Acknowledgement of Receipt of Materials
FR Printed/Typed Name S ogature Month Day year
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19. Discrepancy Indication Space
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T 20.Facility Owner or Operator Certification of receipt of hazardous materials covered by this rtfanifest except as noted in item 19.
=1 Printed yped N me r Signal `j Month! Rdy2�11<ear
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EPA Form 8700-22(Rev.9191) Form Approved OMB No 2050-0039.Expires 9t3 % Previous edition is obsolete.
COPY 3: FACILITY TO GENERATOR
STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMC-Nf
EPHM.2 REV 9191(BACK) - •`
PARTIAL INSTRUCTIONS
FOR COMPLETING THE CONNECTICUT UNIFORM HAZARDOUS WAtTE MANIFEST
IMPORTANT: READ ALL INSTRUCTIONS ON THE COVER SHEET BEFORE COMPLETING THIS FORM ALL 8 COPIES MUST BE TOTALLY LEGIBLE.
GENERAL INFORMATION
The Hazardous Waste Manifest is designed to track waste from the point of generation to final disposal("cradle to grave')-In order to accomplish this goal,it is
essential that all items on the manifest be completed correctly. Incomplete,incorrect or illegible manifests are violations of the law,and could subject you to civil
or criminal liabilities as specified in Connecticut Hazardous Waste Management Regulations-
The Connecticut manifest contains 8 copies ALL COPIES MUST BE LEGIBLE!(Illegible manifests submitted to the State will be returned to the'Generator for
proper completion).This form is designed for use on a 12 pitch(elite)typewriter.A firm ball point pen may also be used only if you press down HARD.The eight
copies must be filed with the appropriate parties as they are completed.
* Be aware that hazardous wastes mani`ested into or out of Connecticut are subject to a hazardous waste assessment per C.G.S.22a-132. Please contact the
Dept of Revenue Services at(203)566-3445 for more information.
COPY DISTRIBUTION Is as follows:
COPY 1: FACILITY MAILS TO DESTINATION STATE: This copy is mailed by the Facility to the responsible state agency in the state in which the facility is
located. upon receipt of the waste.
COPY 2: FACILITY MAILS TO GENERATOR STATE:This copy Is mailed by the facility to the appropriate agency in the Generator's state, upon receipt of the
waste.
COPY 3: FACILITY MAILS TO GENERATOR: This copy is mailed to the generator by the facility upon receipt of the waste. This copy is the generator's
documentation that the facility receivcd the waste.
COPY 4: FACILITY-RETAINS:This copy is retained by the facility for his records.
COPY 5: TRANSPORTER 1 RETAINS:This copy is retained by the Transporter for his records. This copy is the Transporter's documentation that this shipment
was transported from the generator to the facility.
NOTE:If a continuing Transporter is used,the generator is responsible for supplying him with a legible photocopy of the manifest,which must contain
signatures where required.
COPY 6: GENERATOR MAILS TO DESTINATION STATE:This copy is mailed by the generator to the appropriate agency in the destination state(the state in
which the facility is located).
COPY 7: GENERATOR MAILS TO GENERATOR STATE:This copy is mailed by the generator to the appropriate state agency in his state.
COPY 8: GENERATOR RETAINS: This copy is retained by the generator for his records.
GENERATOR SECTION
Item 12: CONTAINERS(NO. &TYPE)-Enter the number of containers for each waste and the appropriate abbreviation from TABLE 1 (below)for the type of;
container used.
TABLE 1 -CONTAINER TYPE �i�. ..-, " `". _• �" <� i." ..,+, a
DM = Metal drums,barrels.kegs TP = Tanks,Portable CM = Metal boxes,cartons,cases(incl.roll offs) e.
OW = Wooden drums,barrels,kegs TT = Cargo Tanks(tank trucks) CW Wooden boxes.cartons.cases 4fi.
DF Fiberboard or plastic drums,barrels,kegs TC = Tank Cars CF Fiber or plastic boxes cartons,cases '
CY Cylinders OT Dump Trucks BA Burlap,cloth.paper,plastic bags
Item 13: TOTAL QUANTITY-Enter the total quantity of waste described on each line,relative to the units used in Item 14.
Item 14: UNIT (Wt./Vol.)-Enter the appropriate abbreviation from Table II (below) for the unit of measure used in determining the total quantity of waste
described on each line. DO NOT use fractions.
TABLE 11-UNITS OF MEASURE
G = Gallons(houids only) L = Liters(liquids only) Y = Cubic Yards
P = Pounds K = Kilograms N = Cubic Meters
= Tons(2000 lb.) M = Metric Tons(1000 kg.)
TRANSPORTER SECTION
Item 17: TRANSPORTER 1 ACKNOWLEDGEMENT-Print or type the name of the person accepting the waste on behalf of the 1st transporter. That person
must acknowledge acceptance of the waste described on the manifest by signing&entering the date of receipt.
Item 18: TRANSPORTER 2 ACKNOWLEDGEMENT-If applicable, follow instructions for Item 17 for Transporter 2.
DESIGNATED FACILITY(TSDF1 SECTION
Item K: HANDLING CODES(TSDF COMPLETES)-Refer to Item K in full instructions.
TABLE III-PROCESS CODESMANDLING METHOD CODES
STORAGE: SOf(Containers) S02(Tank) S03(Waste Pile) SO4(Surface Impoundment) S05(Other-Specify)
TREATMENT: T01 (Tank) T02(Surface Impoundment) T03(Incinerator) (Other Treatment-specify code from 40 CFR 265 Appendix 1).
DISPOSAL. D80 1lnlection well) 081(Landfill) 082(Land Application) D84(Surface Impoundment)
D83(Ocean Disposal) D85(Other-Specify)
Item 19: DISCREPANCY INDICATION SPACE-The authorized representative of the designated facility's c vner or operator must note in this space any
significant discrepancy between the waste described on the manifest&the waste actually received at the facility. Any rejected materials should be
listed here, along with an indication of the disposrtion of the rejected materials. Any applicable Discrepancy or Rejection reporting requirements
must also be complied with. Federal&State regulations vary.
Item 20: FACILITY OWNER OR OPERATOR CERTIFICATION-Print or type the name of the person accepting the waste on behalf of the owner or operator of
the designated TSDF That person must acknowledge acceptance of the waste described on the manifest by signing(by hand)&entering the date of
the receipt.The signature of the authorized TSDF agent indicates acceptance(except for items specified in Item 19)&agreement with the statements
on this manifest.
* NOTE: FOR INTERSTATE SHIPMENTS(between different states)YOU MAY BE REQUIRED TO COMPLY WITH THE MANIFESTING REQUIREMENTS OF
BOTH THE DESTINATION &GENERATOR STATES REGARDING THE COMPLETION OF SPECIFIC INFORMATION INCLUDED IN LETTERED ITEMS A-K
You may wish to contact State agencies for more information on this subject.
REMINDER: ALL 8 COPIES OF THIS FORM MUST BE TOTALLY LEGIBLE.
Public reporting burden for this collection of information is estimated to average:37 minutes for generator, 16 minutes for transporter. 10 minutes for treatment, storage and disposal
facility. This includes time for reviewtrig instructions,gathering data.and completing and revievong the Corm.Send comments regarding the burden estirnale.including suggestions for
reducing this burden.to CHIEF.INFORMATION POLICY BRANCH,PM-223,U,S ENVIRONMENTAL PROTECTION AGENCY,401 M STREET SW WASHINGTON,D-C 20460:and to the
OFFICE OF INFORMATION AND REGULATORY AFFAIRS,OFFICE OF MANAGEMENT AND BUDGET.WASHINGTON.D C.20501
jr Bridgeport United-Recycling, Inc.
Land Ban Notification Form
Generator Name �,�ct� Jil-e Manifest Number 0 6 33
onh=rdous Waste. This waste is not hazardous waste as defined in 40 CFR 261 and is not subject to
regulation under 40 CFR 268.
Hazardous Waste. This waste is hazardocs waste and therefore regulated under 40 CFR 268. This waste is
banned from lmd disposal unless treated to the sundards under 40 CFR 268.40 or specifically exempt under this
Subpart I unierstand that United Oil Recovery.Inc.and Bridgeport United Recycling.Inc.opcate treatment systems
that are regulaed under the CWA. This waste is a wastewater nonwastewater as defued in this Subpart.
The applicabk waste codes are checked below.
Spent Solvent Wastes characteristic Wastes
_F001,_F002,_F003,_F004,_FX05 D001 Ignitable Liquais, High TOC(>10%)
D001 Ignitable Liqui s.Low TOC(<10%)
_Acetone D004 Arsenic
_Benzene D018 Benzene
_n-3utyl Alcohol D006 Cadmium
_Grbon Disulfide D019 Carbon tetract'oride
_Grbon Tetrachloride D021 Chlorobenzen_
_Cilorobenzene D022 Chloroform
—6-.sol(m-and p-isomers) D007 Chromium
_Cr-sol(o-isomer) D023 o-Cresol
_Ctclohexanone D024 m-Cresol
1.2-Dichlorobenzene D025 p-Cresol
_Et iyl Acetate D026 Cresol
_Elbyl Benzene .D027-: 1,4-Dichlorobenzene
_Ediyl Ether 'DOLE' 12-Dichlorocizarie
_lsobutanol D029 13'K ilorocaylene
Wlhanol D030 2,4-Dinitrotoltrne
_W-thylene Chloride D032 Hezachlorobenzene
_Methyl Ethyl Ketone D033 Hezachlorobutidiene
_Methyl Isobutyl Ketone D034 He achloroethine
_Niaobenzene D008 Lead
P ddine D035 Methyl ethyl k.-cone
_Tctrachloroethylene D036 Nitrobenzene
_Teluene D037 Pentrachloroptenol
_1,1,1-Trichloroethane D038 Pyridine
_1.1.2-Trichloroethane DOI I Silver
_1.1.2-Ttichloro-1.2,2-TriQuoroethant D039 Tetrachloroeth-lene
_Trichloroethylene D040 Trichloroethylme
_Tfichlorotluoromethane D041 2,4,5-Trichlortpbenol
_Xylene D042 2,4,6-Tricblorcphenol
D043 Vinyl chloride
It
The informai6a pro-clod hQe is true sod&caste to the best of my Lno,.<dge The intotmatioa hae is stbmdtod solely to cortply-ith the IIR found in 40 CFR 268-(Chtck
here j(the wane kv the treannent sundardr)_I omlify undo poky of law that I pcwoally have eaamised sad a n familiar rich the vac duough analysis and&C,64 a
through knowtaegc cfdhc caste so suppon this cvtiGeatioa that the waa.=aVF=with the sundardc qwXood is 40 CFR Pan 268 subpart D and all applicable Pto6,3it+ooa$ct
forth is 40 CFR 261:2 or RCRA seaioa 3004(d).1 believe a iafar—Jt/ ZAion 1 subaked k true.accrue and eonplccc.I am&care that die.arc siga-scant pest"ror
cu"Un ag a(altc*=rk-1' a.including the postibility o(a cad irt¢yonrteoL `
1 ,
Signature /1 T1tle
Print Name Wl I—L1,6 �. �/�/�N�G Date Z3
EPFAI2AREV ",9, STATE OF CONNECTICUT
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DEPARTMENT OF ENVIRONMENTAL PROTECTION I V i
Hazardous Waste MANIFEST PROGRAM '-- ` r
79 Elm St.,Hartford,CT 06106-5127 t .. rro
Please type(or print)(Form designed for use on elite 112-pitch)typewriter) FOR STATE USE ONLY
UNIFORM HAZARDOUS 1 Generator's US EPA ID No. Manifest 2 Page 1 Intormahon the shaded areas rs not
Document No. required by Federat law, but may bP
WASTE MANIFEST or requited by state law
r 3 Generator's Name and Mailing Address w t^ A.State Manifest Document Number
N It a7 3
B G.S.I. !Gen.Site Address)
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a. 5 Transporter 1 Company Name ' 6 US EPA ID Number s,
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a 7 Transporter 2 Company Name 8 US EPA ID Number S.T I (Trans.Lic. Plate B) M
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. . . . . . . . . Tran. Phone( ) Z
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9 Designated Facility Name/and Site Address ,` 1+ 4,•, 10 US EPA ID Number S.T.I.(Trans.tic. Plate f) >
t F.Tran.Phone( )
o ; t� erFP - G State Facility's ID(Not Required)
't t: r rat ' � . !. H.Facility's Phone a
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12. Containers 13.
0 11. US DOT Description(including Proper Shipping Nanre, Hazard Class, and ID Number) Total a^I! Waste No O
r No Type Ouanlity wuvol
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0 15. Special Handling Instructions and Additional Information
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16 GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by
proper shipping name and are classified,packed,marked, and labeled,and are in all respects in proper condition for transport by highway
w according to applicable international and national government regulations,and all applicable State laws and regulations.
Z If I am a large quantity generator.I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be ♦ /
uj economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present
w and future threat to human health and the environment:OR,if 1 am a small quantity generator,I have made a good faith e'fort to minimize my waste generation and
Z select the best waste management method that is available to me and that I can afford
mPrinted/Typed Name Signature Month Day year
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z T 17. Transporter 1 Acknowledgement of Receipt of Materials
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a A Printed/Typed Name Signatur Month Day Year
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A Printed/Typed Name Signature Month Day year
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19. Discrepancy Indication Space
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20.Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
= Y Printed/Typed Name Signature Month Day Year
Z
EPA Form 8700.22(Rev.9/91) Form Approved OMB No 2050-0039 Expires 9i30r96 Previous edition is obsolete.
COPY 6: GENERATOR MAILS TO DESTINATION STATE
STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMENT
EPH61-2 REV 9191(BACK)
PARTIAL INSTRUCTIONS
FOR COMPLETING THE CONNECTICUT UNIFORM HAZARDOUS WASTE MANIFEST
IMPORTANT READ ALL INSTRUCTIONS ON THE COVER SHEET BEFORE COMPLETING THIS FORM.ALL 8 COPIES MUST BE TOTALLY LEGIBLE
GENERAL INFORMATION
The Hazardous Waste Manifest is designed to track waste from the point of generation to final disposal(`cradle to grave"). In order to accomplish this goal,it is
essential that all items on the manifest be completed correctly incomplete, incorrect or illegible manifests are violations of the law,and could subject you to civil
or criminal liabilities as specified in Connecticut Hazardous Waste Management Regulations.
The Connecticut manifest contains 8 copies ALL COPIES MUST BE LEGIBLE!(Illegible manifests submitted to the State will be returned to the Generator for
proper completion).This form is designed for use on a 12 pitch(elite)typewriter.A firm ball point pen may also be used only it you press down HARD-The eight
copies must be filed with the appropriate parties as they are completed.
* Be aware that hazardous wastes manifested into or out of Connecticut are subject to a hazardous waste assessment per C.G.S.22a-132 Please contact the
Dept. of Revenue Services at(203)566-3445 for more information.
COPY DISTRIBUTION is as follows:
COPY 1: FACILITY MAILS TO DESTINATION STATE This copy is maited by the Facility to the responsible state agency in the state in which the facility is
located.upon receipt of the waste.
COPY 2: FACILITY MAILS TO GENERATOR STATE:This copy is mailed by the facility to the appropriate agency in the Generator's state,upon receipt of the
waste.
COPY 3: FACILITY MAILS TO GENERATOR: This copy is mailed to the generator by the facility upon receipt of the waste. This copy is the generator's
documentation that the facility received the waste.
COPY 4: FACILITY-RETAINS:This copy is retained by the facility for his records.
COPY 5: TRANSPORTER i RETAINS:This copy is retained by the Transporter for his records.This copy is the Transporter's documentation that this shipment
was transported from the generator to the facility.
NOTE:If a continuing Transporter is used,the generator is responsible for supplying him with a legible photocopy of the manifest,which must contain
signatures where required.
COPY 6: GENERATOR MAILS TO DESTINATION STATE:This copy is mailed by the generator to the appropriate agency in the destination state(the state in
which the facility is located).
COPY 7: GENERATOR MAILS TO GENERATOR STATE. This copy is mailed by the generator to the appropriate state agency in his state.
COPY 8: GENERATOR RETAINS: This copy is retained by the generator for his records.
GENERATOR SECTION
Item 12: CONTAINERS(NO. &TYPE)-Enter the number of containers for each waste and the appropriate abbreviation from TABLE 1 (below)for the type of
container used.
TABLE 1 -CONTAINER TYPE
DM = Metal drums,barrels.kegs TP = Tanks.Portable CM = Metal boxes,cartons,cases(incl.roll-offs)
DW = Wooden drums,barrels,kegs TT = Cargo Tanks(tank trucks) CW = Wooden boxes.cartons.cases
DF = Fiberboard or plastic drums.barrels,kegs TC = Tank Cars CF = Fiber or plastic boxes cartons,cases
CY = Cylinders DT = Dump Trucks BA - Burlap,cloth,paper,plastic bags
Item 13: TOTAL QUANTITY-Enter the total quantity of waste described on each line, relative to the units used in Item 14.
Item 14: UNIT (Wt./Vol.)-Enter the appropriate abbreviation from Table II (below) for the unit of measure used in determining the total quantity of waste
described on each line. DO NOT use fractions.
TABLE 11-UNITS OF MEASURE
G = Gallons(liquids Only) L = Liters(liquids only) Y = Cubic Yards
P = Pounds K = Kilograms N = Cubic Meters
T = Tons(2000 Ib.) M = Metric Tons(1000 kg.)
TRANSPORTER SECTION
Item 17: TRANSPORTER 1 ACKNOWLEDGEMENT-Print or type the name of the person accepting the waste on behalf of the 1st transporter. That person
must acknowledge acceptance of the waste described on the manifest by signing&entering the dale of receipt.
Item IS: TRANSPORTER 2 ACKNOWLEDGEMENT-if applicable,follow instructions for Item 17 for Transporter 2.
DESIGNATED FACILITY (TSDF)SECTION
Item K: HANDLING CODES(TSDF COMPLETES)-Refer to Item K in full instructions.
TABLE III-PROCESS CODES/HANDLING METHOD CODES
STORAGE: S01(Containers) S02(Tank) S03(Waste Pile) SO4(Surface Impoundment) S05(Other-Specify)
TREATMENT: Tot ;Tank) T02(Surface Impoundment) T03(Incinerator) (Other Treatment-s -pecity code from 40 CFR 265 Appendix I}.
DISPOSAL
D80(Injection well) 081(Landfill) DB2(Land Application) D84(Surface Impoundment)
;.. •it3� ~��r D83(Ocean Disposal) D85'Other-Specify)
Item 19: DISCREPANCY INDICATION SPACE-The authorized representative of the designated facility's c caner or operator must note in this space any
significant discrepancy between the waste described on the manifest&the waste actually received at the facility Any rejected materials should be
listed here. along with an indication Of the disposition of the rejected materials. Any applicable Discrepancy or Rejection reporting requirements
must also be complied with. Federal&State regulations vary.
Item 20: FACILITY OWNER OR OPERATOR CERTIFICATION-Print or type the name of the person accepting the waste on behalf of the owner or operator of
the designated TSDF. That person must acknowledge acceptance of the waste described on the manifest by signing(by hand)&entering the date of
the receipt The signature of the authorized TSDF agent indicates acceptance(except for items specified in Item 19)&agreement with the statements
on this manifest.
* NOTE: FOR INTERSTATE SHIPMENTS(between different states)YOU MAY BE REQUIRED TO COMPLY WITH THE MANIFESTING REQUIREMENTS OF
BOTH THE DESTINATION &GENERATOR STATES REGARDING THE COMPLETION OF SPECIFIC INFORMATION INCLUDED IN LETTERED ITEMS A-K.
You may wish to contact State agencies for more information on this subject,
REMINDER:ALL 8 COPIES OF THIS FORM MUST BE TOTALLY LEGIBLE.
Public reporting burden for this collection of information is estimated to average:37 mtnutes for generator. 15 minutes for transporter, to minutes for treatment.storage and disposal
facility_ This includes time for reviewing instructions,gathering data.and completing and reviewing the form Send comments regarding the burden estimate.imfuding suggestions for
reducing this burden,to CHIEF.INFORMATION POLICY BRANCH,PM-223,U.S ENVIRONMENTAL PROTECTION AGENCY,401 M STREET SW.WASHINGTON,D.C.20460:and to the
OFFICE OF INFORMATION AND REGULATORY AFFAIRS.OFFICE OF MANAGEMENT AND BUDGET.WASHINGTON.D.C.20501
EPFIM-2A REV,lit" STATE OF CONNECTICUT
I
DEPARTMENT OF ENVIRONMENTAL PROTECTION
T, Hazardous Waste MANIFEST PROGRAM
7 79 Elm St.,Hartford,CT 06106-5127 ------
Ptease type(or print)(Form designed ter;tie on elite(12-pitch)typewriter./ FR S OTATE USE ONLY
m UNIFORM HAZARDOUS 1 Generator's US EPA ID No Manrfest 2 Page i nrorr aeon in the shaded areas 6not
Document No requred by Federal taw. but may
WASTE MANIFEST required by Slate law.
3. Generators Name and Mailing Address A.State Manifest Document'Number
N CT F 0533637
a S G.S-I. {Gen_Site Address) n
0 4. Generator's Phone( 1 ODD
a 5 Transporter 1 Company Name 6. US EPA ID Number
wIr
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a 7 Transporter 2 Company Name 8. US EPA ID Number C S.T I. (Trans.Lic. Plate#) M
a '. D.Tran. Phone( ) m
9 Designated Facility Name and Site Address 10, US EPA ID Number E.S.T.I.(Trans. Lic.Plate#} >
Ak ,I � " F.Tran.Phone )
o � _ * "' G State Facility's ID(Not Required)
a
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0
• 12.Containers 13 14 r
w 11 US DOT Description(Including Proper Shipping Nanie, Hazard Class, and ID Numberl Total unit I I4
Waste No.
No Type Quantity wtfvoi O
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o Point of Departure:
16 GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by
proper shipping name and are classified,packed, marked,and labeled,and are in all respects in proper condition for transport by highway
according to applicable international and national government regulations,and all applicable State laws and regulations.
w
Z If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be a
cwi economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present ellei
w and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and
Z select the best waste management method that is available to me and that I can afford
a. Printed/Typed Name Signature r a ky t - Month Day year
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o R 17, Transporter 1 Acknowledgement of Receipt of Materials
F- A Printed/Typed Name Signature Month Day rear
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O 18, Transporter 2 Acknowledgement of Receipt of Materials )
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19. Discrepancy Indication Space
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w T 1 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19
Z Y Ponted/Typed Name Signature Mo.rn Day vear
z .
EPA Form 8700.22(Rev.R191) Form Approved OMB No 2050-0039 Expires 9/341% Previous adilwn is obsolete,
COPY 7: GENERATOR MAILS TO GENERATOR STATE
STI ATE OF CONNECTICUi DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMENT
PARTIAL INSTRUCTIONS
FOR COMPLETING THE CONNECTICUT UNIFORM HAZARDOUS WASTE MANIFEST
IMPORTANT READ ALL INSTRUCTIONS ON THE COVER SHEET BEFORE COMPLETING THIS FORM ALL 8 COPIES MUST BE TOTALLY LEGIBLE
GENERAL INFORMATION
The Hazardous Waste Manifest is designed to track waste`rcnt the point of generation to final disposal('cradle to rave"). In order to accomplish this goal,it is
essential that all items on the manifest be completed correctly. incomplete,incorrect or illegible?fiahifests are violations of the law,and could subject you to civil
or criminal liabililies as specified in Connecticut Hazardous Waste Management Regulations.
The Connecticut manifest contains 8 copies. ALL COPIES MUST BE LEGIBLE!(Illegible manifests submitted to the State will be returned to the Generator for
proper completion).This form is designed for use on a 12 pitch(elite)typewriter.A firm bail point pen may also be used only if you press down HARD.The eight
copies must be filed with the appropriate parties as they are completed.
Be aware that hazardous wastes mani`.ested into or out of Connecticut are subject to a hazardous waste assessment per C.G S. 22a-132- Please contact the
Dept. of Revenue Services at(203)566-3445 for more information.
COPY DISTRIBUTION is as to!lows:
COPY 1: FACILITY MAILS TO DESTINATION STATE: This copy is mailed by the Facility to the responsible state agency in the state in which the facility is
located, upon receipt of the waste
COPY 2: FACILITY MAILS TO GENERATOR STATE:This copy is mailed by the facility to the appropriate agency in the Generator's state, upon receipt of the
waste.
COPY 3: FACILITY MAILS TO GENERATOR: This copy is mailed to the generator by the facility upon receipt of the waste. This copy is the generator's
documentation that the lacdity received the waste.
COPY 4: FACILITY-RETAINS. This copy is retained by the facility for his records.
COPY 5: TRANSPORTER 1 RETAINS:This copy is retained by the Transporter for his records.This copy is the Transporter's documentation that this shipment
was U,ansported from the generator to the facility.
NOTE.If a continuing Transporter is used,the generator is responsible for supplying him with a legible photocopy of the manifest,which must contain
signatures where required.
COPY 6: GENERATOR MAILS TO DESTINATION STATE:This copy is mailed by the generator to the appropriate agency in the destination state(the state in
which the facility is located).
COPY 7: GENERATOR MAILS TO GENERATOR STATE:This copy is mailed by the generator to the appropriate state agency in his state.
COPY 8: GENERATOR RETAINS This copy is retained by the generator for his records.
GENERATOR SECTION
Item 12: CONTAINERS(NO &TYPE)-Enter the number of containers for each waste and the appropriate abbreviation from TABLE 1 (below)for the type of
container used-
TABLE 1-CONTAINER TYPE
DM = Metal drums.barrels.kegs TP = Tanks,Portable CM = Meta boxes,cartons,cases find.roll-offs)
DW = Wooden drums;barrels,kegs TT = Cargo Tanks(lank trucks) CW = Wooden boxes.cartons.cases
DF = Fiberboard or plastic drums.barrels,kegs TC = Tank Cars CF = Fiber or plastic boxes cartons,cases
CY = Cylinders DT = Dump Trucks BA = Burlap,cloth.paper,plastic bags
Item 13: TOTAL QUANTITY-Enter the total quantity of waste described on each line,relative to the units used in Item 14.
Item 14: UNIT (Wt./Vol.)-Enter the appropriate abbreviation from Table II (below) for the unit of measure used in determining the total quantity of waste
described on each line. DO NOT use fractions.
TABLE 11-UNITS OF MEASURE
G = Gallons(liquids only L = Liters(liquids only) Y = Cubic Yards
P = Pounds K = Kilograms N = Cubic Meters
T = Tons(2000 lb.) M = Metric Tons(1000 kg.)
TRANSPORTER SECTION
Item 17. TRANSPORTER i ACKNOWLEDGEMENT-Print or type the name of the person accepting the waste on behalf of the 1st transporter.That person
must acknowledge acceptance of the waste described on the manifest by signing&entering the date of receipt.
Item 18: TRANSPORTER 2 ACKNOWLEDGEMENT-If applicable, follow instructions for Item 17 for Transporter 2.
DESIGNATED FACILITY(TSDF)SECTION
Item K: HANDLING CODES(TSDF COMPLETES)-Refer to Item K in full instructions.
TABLE IIi-PROCESS CODES/HANDLING METHOD CODES
STORAGE: 901(Containers) S02(Tank) SOS(Waste Pile) SO4(Surface Impoundment) S05(Other-Specify)
TREATMENT: Tot (Tank) T02(Surface Impoundment) T03(Incinerator) (Other Treatment-specify code from 40 CFR 265 Appendix 1).
DISPOSAL: 080(Injection well) D81(Landfill) D82(Land Application) D84(Surface Impoundment)
D83(Ocean Disposa#j D85(Other-Specify)
Item 19: DISCREPANCY INDICATION SPACE-The authorized representative of the designated facility's c wrier or operator must note in this space any
significant discrepancy between the waste described on the manifest&the waste actually received at the facility. Any rejected materials should be
listed here, along with an indication of the disposition of the rejected materials Arty applicable Discrepancy or Rejection reporting requirements
must also be complied with. Federal&State regulations vary.
Item 20: FACILITY OWNER OR OPERATOR CERTIFICATION-Print or type the name of the person accepting the waste on behalf of the owner or operator of
the designated TSDF That person must acknowledge acceptance of the waste described on the manifest by signing(by hand)&entering the date of
the receipt.The signature of the authorized TSDF agent indicates acceptance(except for items specified in Item 19)&agreement with the statements
on this manifest.
NOTE: FOR INTERSTATE SHIPMENTS(between different states)YOU MAY BE REQUIRED TO COMPLY WITH THE MANIFESTING REQUIREMENTS OF
BOTH THE DESTINATION & GENERATOR STATES REGARDING THE COMPLETION OF SPECIFIC INFORMATION INCLUDED IN LETTERED ITEMS A-K.
You may wish to contact State agencies for more information on this subject
REMINDER: ALL 8 COPIES OF THIS FORM MUST BE TOTALLY LEGIBLE.
Public reporting burden for this collection of information is estimated to average:37 minutes for generator. 15 minutes for irilirisponer, 10 minutes for treatment, storage and disposal
facility This includes time for reviewing instructions,gathering data.ano completing and reviewing the lorm.Send comments regarding the burden estimate.including suggestion8 for
reducing this burden.to CHIEF.INFORMATION POLICY BRANCH,PM-223.U.S.ENVIRONMENTAL PROTECTION AGENCY,401 M STREET SW.WASHINGTON.D.C.20460-and to the
OFFICE OF INFORMATION AND REGULATORY AFFAIRS.OFFICE OF MANAGEMENT AND BUDGET.WASHINGTON.D.C.20503.
EPHW2A REV.
11194 STATE OF CONNECTICUT
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
_ 3 Hazardous Waste MANIFEST PROGRAM
79 Elm St.,Hartford,CT 06106-5127 '.--_ -----
Please type(or print)(Form deslgne:J for use on eMe i 12-pitch)typewriter/ FOR STATE USE ONLY
UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2 Page 1 Intormation m the shaded areas is
,.� Document NO. required byFederal iaw out may
WASTE MANIFEST . . . . . . • of required by State law
� 3 Generator's Name and Mailing Address A.State Manifest Document Number
N CT F 0533637
a B G.S.I. ,Gen.Site Address) n
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o G. State Facility's ID(Not Required)
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v; 16 GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by
=i proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway
w according to applicable international and national government regulations. and all applicable State laws and regulations.
Z If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be
Lu
economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present
w and future threat to human health and the environment,OR.if I am a small quantity generator,I have made a good faith edort to minimize my waste generation and
Z select the best waste management method that is available to me and that I can afford
NPrinted/Typed Name Signature Month Day year
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EPA Form 8700-22(Rev.9/91) Form Approved OMB No 2050-0039 Expires 9/3W96 Previous edition is obsolete.
COPY 8: GENERATOR RETAINS
STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WASTE MANAGEMENT
EPHM.2 REV 9/91(BACK)
PARTIAL INSTRUCTIONS
FOR COMPLETING THE CONNECTICUT UNIFORM HAZARDOUS WASTE MANIFEST
IMPORTANT:READ ALL INSTRUCTIONS ON THE COVER SHEET BEFORE COMPLETING THIS FORM.ALL 8 COPIES MUST BE TOTALLY LEGIBLE.
GENERAL INFORMATION
The Hazardous Waste Manifest is designed to track waste from the point of generation to final disposal("cradle to grave").In order to accomplish this goal,it is
essential that all items on the manifest be completed correctly.Incomplete,incorrect or illegible manifests are violations of the law,and could subject you to civil
or criminal liabilities as specified in Connecticut Hazardous Waste Management Regulations.
The Connecticut manifest contains 6 copies.ALL COPIES MUST BE LEGIBLE!(Illegible manifests submitted to the State will be returned to the Generator for
proper completion).This form is designed for use on a 12 pitch(elite)typewriter.A firm ball point pen may also be used only if you press down HARD.The eight
copies must be filed with the appropriate parties as they are completed.
* Be aware that hazardous wastes manifested into or out of Connecticut are subject to a hazardous waste assessment per C.G.S.22a-132. Please contact the
Dept.of Revenue Services at(203)566-3445 for more information.
COPY DISTRIBUTION is as follows:
COPY 1: FACILITY MAILS TO DESTINATION STATE: This copy is mailed by the Facility to the responsible state agency in the state in which the facility is
located,upon receipt of the waste.
COPY 2: FACILITY MAILS TO GENERATOR STATE:This copy is mailed by the facility to the appropriate agency in the Generator's state,upon receipt of the
waste.
COPY 3: FACILITY MAILS TO GENERATOR: This copy is mailed to the generator by the facility upon receipt of the waste. This copy is the generator's
documentation that the facility received the waste.
COPY 4: FACILITY-RETAINS:This copy is retained by the facility for his records.
COPY 5: TRANSPORTER 1 RETAINS:This copy is retained by the Transporter for his records.This copy is the Transporter's documentation that this shipment
was transported from the generator to the facility.
NOTE:If a cohtinuing Transporter is used,the generator is responsible for supplying him with a legible photocopy of the manifest,which must contain
signatures where required.
COPY 6: GENERATOR MAILS TO DESTINATION STATE:This copy is mailed by the generator to the appropriate agency in the destination state(the state in
which the facility is located).
COPY 7: GENERATOR MAILS TO GENERATOR STATE:This copy is mailed by the generator to the appropriate state agency in his state.
COPY S. GENERATOR RETAINS:This copy is retained by the generator for his records.
GENERATOR SECTION
Item 12: CONTAINERS(NO. &TYPE) Enter the number of containers for each waste and the appropriate abbreviation from TABLE 1 (below)for the type of
container used.
TABLE 1 -CONTAINER TYPE
DM = Metal drums,barrels,kegs TP = Tanks,Portable CM = Metal boxes,cartons,cases(incl.roll-offs)
DW = Wooden drums,barrels,kegs TT = Cargo Tanks(tank trucks) CW - Wooden boxes,cartons,cases
DF = Fiberboard or plastic drums.barrels,kegs TC = Tank Cars CF = Fiber or plastic boxes cartons,cases
CY = Cylinders DT = Dump Trucks BA = Burlap.cloth.paper,plastic bags
Item 13: TOTAL QUANTITY-Enter the total quantity of waste described on each line,relative to the units used in Item 14.
Item 14: UNIT (Wt./Vol,) Enter the appropriate abbreviation from Table II (below)for the unit of measure used in determining the total quantity of waste
described on each line. DO NOT use fractions.
TABLE II-UNITS OF MEASURE
G - Gallons(liquids only) L - Liters(liquids only) Y = Cubic Yards
P = Pounds K = Kilograms N = Cubic Meters
T = Tons(2000 Ib.) M = Metric Tons(1000 kg.)
TRANSPORTER SECTION
Item 17: TRANSPORTER 1 ACKNOWLEDGEMENT-Print or type the name of the person accepting the waste on behalf of the 1st transporter.That person
must acknowledge acceptance of the waste described on the manifest by signing&entering the date of receipt.
Item 18: TRANSPORTER 2 ACKNOWLEDGEMENT-If applicable,follow instructions for Item 17 for Transporter 2.
DESIGNATED FACILITY(TSDF)SECTION
Item K: HANDLING CODES(TSDF COMPLETES)-Refer to Item K in full instructions.
TABLE III-PROCESS CODES/HANDLING METHOD CODES
STORAGE: Sol(Containers) S02(Tank) S03(Waste Pile) SO4(Surface Impoundment) S05(Other-Specify)
TREATMENT: Tot(Tank) T02(Surface Impoundment) T03(Incinerator) (Other Treatment-specify code from 40 CFR 265 Appendix 1).
DISPOSAL: D80 f Injection well) D81(Landfill) D82(Land Application) 084(Surface Impoundment)
083(Ocean Disposal) D85(Other-Specify)
Item 19: DISCREPANCY INDICATION SPACE-The authorized representative of the designated facility's c+vner or operator must note in this space any
significant discrepancy between the waste described on the manifest&the waste actually received at the facility.Any rejected materials should be
listed here,along with an indication of the disposition of the rejected materials. Any applicable Discrepancy or Rejection reporting requirements
must also be complied with.Federal&State regulations vary.
Item 20: FACILITY OWNER OR OPERATOR CERTIFICATION-Print or type the name of the person accepting the waste on behalf of the owner or operator of
the designated TSDF.That person must acknowledge acceptance of the waste described on the manifest by signing(by hand)&entering the date of
the receipt.The signature of the authorized TSDF agent indicates acceptance(except for items specified in Item 19)&agreement with the statements
on this manifest.
* NOTE: FOR INTERSTATE SHIPMENTS(between different states)YOU MAY BE REQUIRED TO COMPLY WITH THE MANIFESTING REQUIREMENTS OF
BOTH THE DESTINATION &GENERATOR STATES REGARDING THE COMPLETION OF SPECIFIC INFORMATION INCLUDED IN LETTERED ITEMS A-K.
You may wish to contact State agencies for more information on this subject.
REMINDER:ALL 8 COPIES OF THIS FORM MUST BE TOTALLY LEGIBLE.
Public reporting burden for this collection of information is estimated to average:37 minutes for generator. 15 minutes for transporter, 10 minutes for treatment,storage and disposal
facility.This includes time for reviewing instructions,gathering data.and completing and reviewing the form.Send comments regarding the burden estimate,including suggestions for
reducing this burden,to CHIEF,INFORMATION POLICY BRANCH.PM-223.U.S.ENVIRONMENTAL PROTECTION AGENCY,401 M STREET SW,WASHINGTON,D C.20460.and to the
OFFICE OF INFORMATION AND REGULATORY AFFAIRS.OFFICE OF MANAGEMENT AND BUDGET,WASHINGTON.D C.20503.
INSTRUCTIONS
FOR COMPLETING THE CONNECTICUT UNIFORM HAZARDOUS WASTE MANIFEST
IMPORTANT: READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM.ALL 8 COPIES MUST BE TOTALLY LEGIBLE.
GENERAL INFORMATION
The Hazardous Waste Manifest is designed to track waste from the point of generation to final disposal("cradle to grave"). In order to accomplish this
goal, it is essential that all items on the manifest be completed correctly.
Incomplete, incorrect or illegible manifests are violations of the law, and could subject you to civil or criminal liabilities as specified in Connecticut
Hazardous Waste Regulations.
The Connecticut manifest contains 8 copies. ALL COPIES MUST BE LEGIBLE! (Illegible manifests submitted to the State will be returned to the
Generator for proper completion).This form is designed for use on a 12 pitch(elite)typewriter.A ball point pen may also be used only if you press down
HARD. The eight copies must be filed with the appropriate parties as they are completed.
* Be aware that hazardous wastes manifested into or out of Connecticut are subject to a hazardous waste assessment per C.G.S 22a-132. Please
contact the Dept. of Revenue Services at(203)566-3445 for more information.
USE OF THE MANIFEST
This manifest must be used for RCRA regulated hazardous wastes. It may also be used for state regulated hazardous wastes, or for other state
regulated special wastes for which state regulations Require the use of this manifest.
Wastes which are not federally or state regulated may only appear on a manifest in a mixed shipment. RCRA regulated hazardous wastes should be
listed first,then the state regulated wastes,then non-hazardous wastes.(Non-hazardous non-regulated wastes,like empty drums which are regulated by
DOT, may also be listed under Item 15).
Copy Distribution Instructions are found on the back of the form along with tables and instructions for the transporter and facility.
GENERATOR SECTION
Item 1: GENERATOR'S US EPA ID NO-MANIFEST DOCUMENT NO.-Enter U.S. EPA 12 digit identification number(CT Conditionally Exempt Small
Quantity Generators who have not obtained an EPA 10 number should enter the letters"CESQG"here).Then enter a UNIQUE 5 digit number
you assign to this manifest. Use of serially increasing numbers(eg. 00001,00002,etc.)is recommended.
Item 2: PAGE 1 of-Enter the total number of pages used to complete this manifest. If you use more than one manifest for a shipment make sure to
cross-reference each of the manifests in Item 15, by state manifest document numbers.
Item A: STATE MANIFEST DOCUMENT NUMBER-Number preprinted by CT.
Item 3: GENERATOR'S NAME&MAILING ADDRESS-Enter the name(as notified to EPA)&mailing address of the Generator.This address should
be the location that will manage the returned manifest forms.(However,a manifest copy must be kept at the actual site).
Item 4: GENERATOR'S PHONE NUMBER-Enter the phone number of someone who is knowledgeable about this shipment,and who can respond to
questions regarding the information on this manifest, or in case of an emergency(24 hrs).
Item B: G.S.I.(Gen.Site Address)-Enter the location address of the Generator-street,city(and state if different)where the waste is being picked up.
Enter 'same" if the mailing address and location address are identical.
Item 5: TRANSPORTER 1 COMPANY NAME-Enter the company name(as notified to EPA)of the first transporter who will transport the waste.
Item 6: US EPA ID NUMBER-Enter the US EPA 12 digit identification number of the first transporter identified in Item 5.
Item C: S.T.I. (Trap. Lic. Plate 4)-Enter the state of registration and then the license plate number of the waste carrying portion of the vehicle.(e.g.,
NY 14235). NOTE: ALL HAZARDOUS WASTE TRANSPORTERS OPERATING IN CONNECTICUT MUST HAVE A VALID CONNECTICUT
TRANSPORTERS PERMIT.
Item D: TRANSPORTER'S PHONE-Enter a telephone number with area code where an authorized agent of the transporter can be reached.
Item 7: TRANSPORTER 2 COMPANY NAME-If applicable enter the company name(as notified to EPA)of the 2nd transporter who will transport the
waste. Whenever more than two transporters or four waste streams are involved in a shipment, the Generator shall fully complete additional
manifests, listing the additional information.
Item 8: US EPA ID NUMBER-If applicable, enter the US EPA 12 digit identification number of the 2nd transporter identified in Item 7.
Item E: S.T.I. (Tran. Lic. Plate*)-If applicable,enter the 2nd transporter's state of registration&license plate number for the waste carrying portion
of the vehicle being used to make the pick-up.
Item F: TRANSPORTER'S PHONE - If applicable, enter the 2nd transporter's telephone number with area code where an authorized agent of the
transporter can be reached.
Item 9: DESIGNATED FACILITY NAME & SITE ADDRESS - Enter the company name (as notified to EPA) of the Treatment, Storage, or Disposal
Facility designated to receive the waste listed on the manifest. The address must be the site address, which may differ from the mailing
address.
Item 10: US EPA ID NUMBER-Enter the U.S. EPA 12 digit identification number of the designated Facility identified in Item 9.
Item G: STATE FACILITY ID-No entry required by Connecticut.
Item H: FACILITY PHONE-Enter the telephone number with area code for the Facility designated to receive the waste on the manifest.
Item 11: US DOT DESCRIPTION-All the following information must be entered:The correct US DOT(Dept.of Transportation)name for the waste as
identified in 49 CFR Parts 171-177(usually found in Column 2 of Section 172.101),the assigned DOT Hazard Class(usually found in Column
3)&the 4 digit UN/NA ID number(Column 3A).(Example:Waste acetone,flammable liquid, RQ UN 1090(F003). US DOT requires the
word "waste'' before or in the shipping name of all hazardous waste.
Item 12: CONTAINERS(NO. &TYPE)-Enter the number of containers for each waste and the appropriate abbreviation from TABLE I(below)for the
type of container used.
TABLE I-CONTAINER TYPE
DM-Metal drums barrels.kegs TP-Tanks.Portable CM. Metal boxes,canons.cases(incl.roll-otts)
ow=wooden orums barrels.kegs TT=cargo Tanks(tank trucks) CW=Wooden boxes.canons cases
DF . Fiberboard or plastic drums,barrels,kegs TIC.Tank Cars OF. Fber or plastic boxes.cartons.cases
CV = coraws DT =Dumo Trucks BA-Burlap cloth paper.plastic bags
i
Item 13: TOTAL QUANTITY-Enter the total quantity of waste described on each line, relative to the units used in Item 14.
Item 14: UNIT(Wt.Nol.)- Enter the appropriate abbreviation from Table 11(below)for the unit of measure used in determining the total quantity of
waste described on each fine. DO NOT use fractions.
TABLE 11- UNITS OF MEASURE
G.Cations(liquids onb) L•Users(Spuids onry) Y-Cubic Yards
P-Pounds K.Kdo7vn H.Cubic Meters
T.Tons OW m.) M.Metric Tons 11000 kg.)
Item I: WASTE NO:EPA-Enter the EPA waste number from 40 CFR Part 261,Subparts C&D.If none is applicable,enter"NONE" DO NOT leave
blank. Enter other applicable EPA waste codes under Item J.
WASTE NO:STATE-Enter the Destination State Waste Code if one exists. If there is no Destination State Waste Code,enter the Generator
State Code here. If there is both a Destination and Generator State Code, enter the Destination State Waste Code under Item 1, and the
Generator State Code under Item J. If no State Waste Code exists,enter "NONE"
Note: Place an asterisk(*) after the waste no. for waste which generators believe qualifies for exemption under Generator tax act C.G.S.
22a-132 and cite reason for exemption under Item J.
Item J: ADDITIONAL DESCRIPTIONS FOR MATERIALS LISTED ABOVE Enter the following information: For each waste listed in Item 11 (a-e)
above,list:
Other applicable waste codes in addition to those listed under Item I.
The specific gravity for items listed in gallons, liters or cubic yards under Item 14.
The physical state(liquid/solid/gas),if not part of D.O.T.shipping name.
ill Description(criemical names,constituent percentages,etc.)for any waste which has a US DOT shipping name ending in "N.O.S."
Item 15: SPECIAL HANDLING INSTRUCTIONS & ADDITIONAL INFORMATION Use this scace to indicate specia'transport. treatment, storage or
cisposa!, or Bill of Lacing imo matron. If an alternate facility is cesignated. note it here. For INTERNATIONAL SHIPMENTS.the Generator
must enter here the point of departure from the U.S.through which the waste must travel before entering a foreign country(City&State).This
space may a!so be used for emergency response numbers,and other information the Generator wishes to include about the shipment. For
Exports-Transporters must sign and enter the date the waste left the United States in this space.
Item K: HANDLING CODES-To be completed by receiving facility.
If final disposition is to occur at the facility, enter the appropriate handling code from 40 CFR, Part 265.Appendix I.Table 2 for each waste
listed on this manifest under"Final"
If ultimate disposition will not occur at the facility listed on this manifest,enter the appropriate handling code from the table in 40 CFR under
"Interi... (the ultimate handling method employed at your facility). Then enter the final handling method code which is intended for each
waste listed on the manifest under the column entitled "Final" (Examp'e:Waste is being stored in containers at facility on this manifest.
Waste will then be transhipped to another facility where is will be incinerated. Enter"S01" under"Interim", and"T08" under"Final".)
Item 16: GENERATOR'S CERTIFICATION-The Generator must read.sign(by hard)&date the certification(with date of transfer to transporter). If a
moce other than highway is used,the word "highway"should be lined out&the appropriate mode(rail, water, or air)inserted in the space
below. If another mode in addition to the highway mode is used, enter the appropriate mode (e.g. "and rail") in space below. Primary
exporters shipping hazardous waste to a facility located outside of the United States must add to the end of the first sentence of the
certification the following words "and conforms to the terms of the EPA Acknowledgement of Consent to the shipment."
TRANSPORTER SECTION
:tem 17: TR ".S°ORTER 1 ACKNOWLEDGEMENT-Print or type the name of the person accepting the waste on beha!f of the 1st transporter.That
person must acknowledge acceptance of the waste described on the manifest by signing and entering the date of receipt.
Item 18: TRANSPORTER 2 ACKNOWLEDGEMENT-if applicable,follow the instructions for Item 17 for Transporter 2.
DESIGNATED FACILITY (TSDF) SECTION
Item K: HANDLING CODES(TSDF COMPLETES)-Follow Instructions for Item K listed above.
Item 19: DISCREPANCY INDICATION SPACE-The authorized representative of the designated `.agility's owner or operator must note in this space
any significant discrepancy between the waste described on the nar,ifest&the waste actua'ly rece^red at the facility.Any re;ected materials
snouid be listed here, along with an indication of the disposition of the rejected materials. A receiving faci!;ty vinose EPA ID number is
different from the one listed in Item 10 shall list the correct EPA ID number.facility name and address here.You mast also comply with any
applicable Discrepancy or Rejection reporting requirements. Federal and State regulations vary.
tem 20: FACILITY OV NER OR OPERATOR CERTIFICATION- Print or ripe the name of the persor accepting the waste on behalf oT the owner or
operator of the design ated,TSD F.That person must acknowledge acgeptance of the waste described on the mandes:by signing by hand)&
entering t cope of re _.t.. The signature or theauthorized TSDF agent indicates acceptance (except for i.e^i_ spegif.e in Item 19) &
agreement with statements on this manifest.
dote: FOR iNTERSTA i E SHIPMENTS (between different states) YOU SHOULD COMPLETE THE MANIFEST ACCORDINU TO THE DESTINATION
3TATE'S IN T RUCTIONS. YOU MAY BE REQUIRED TO COMPLY WiTH OTHER REGULATIONS (and Generator State instructions) regarding the
manifest.You may wish to contact your State agencies for more information on this subject.
REMINDER: ALL 8 COPIES OF THIS FORM MUST BE TOTALLY LEGIBLE.
UT
UNDEOGROUND STORAGE PG. of Sent of E COnmental Pr
Department of Environmental Protection EPHM-6 NEW 10'85
FACILITY NOTIFICATION r UNDERGROUND STORAGE FACILITIES PROGRAM 3. FOR STATE A SITE I.D.
•Q - HAZARDOUS MATERIALS MANAGEMENT UNIT
Z 165 Capitol Avenue,Hartford,CT 06106 AGENCY USE ONLY
® FIRST _ - TEL. 556-4630 B.DATE RCVD BY D.E.P C.DATE ENTERED
NOTIFICATION -
luL OR
N PLEASE TYPE.ALL THREE COPIES MUST BE LEGIBLE! ~" FG1IDOORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS?
SUBSEQUENT (lichecked,b. ❑ NOTIFICATION enter No.) Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form. Y ❑YES ❑NO
LOCATION SITE NAME NO.AND STREET k NEAREST INTERSECTING STREET CITY OR TOWN STATE 5 LATITUDE t i LONGITUDE t tt
4. OF FACILITY
CBfCjtIBTtE'rS T?tJtQn .'Z� Dim � South Windsor
BUSINESS NAME AN ~ n S _ CITY OR': STATE ZIP i^OPF TELEPHONE
6. MAILING ADDRESS $O. Windsor �e Den_ ,___- _ ^ R _ South Wl s0r �074--- ' �-=-pi5r47—
m NAME NO.AND STREET CITY OR TOWN STATE ZIP CO[ TELEPHONE
0 7. FACILITY OWNER Town of South Windsor 540 Sullivan Av ue S u �T_indsQr 06074 (203�-644-2511_
f-
N B. TYPE OF OWNER ❑ PRIVATE ❑ STATE MUNICIPAL ❑ FEDERAL(G.S.A-No.
OPERATOR/CONTACI NAME NO.AND STREET CITY OR TOWN STATE[ZIP CODE' TELEPHONE
9. PERSON William R. Lanning 1175 Ellin ton d. South Windsor Ift 06074 In 1_
10. 110. 11b. 12a. 12 b. STATUS 13. TYPE OF IA. CONTENTS- 15�CONSTRUCTION 16.PROTECTION 17.INTEGRAL
IN NAL b.EXTERNAL PIPING SYSTEM 18. 19. FAILURE
> DATE CONTENTS MATERIALS '
DATE OF Z_ TOTAL p J EST.QUANTITY CHEMICAL NAME F PRINCIPAL Z a. b. DATE OF MONITORING DETERMINATION
TANK ID' INSTALLATION `-o CAPACITY Z v J LEFT STORED p TANK j SUBSTANCE �W < v O �o v Z z z _ INSTALLATION
V u �. 0— o w O o SYSTEM CONDUCTED.
a, (Gals.) O Q > LAST Q I 0,; �w V r a ~ w'rm a < OR
f ) Q I O U (not trade name.) 00 w'- O O V _ (If"YES",enter DATE"
Mo.i Yr. x a w a (if any). O w z O W 2 Q m' Z S w Q Q S w = o- F Z
§ a z USED a a F— (Enter C.A.$. No. 1 known) Z as w ~ t- n E = REPLACEMEUIT
Q Z 1 (Gals.) j w m-a- O`s Q O O O i O • (Specify type and attach results).
m- w _f =o !- i Z vo v3 <O o Mo. Yr.Z Q I (/V10./Yf.) O J U J " 7 or U a o 1 / ) from lost 81 If"NO",enter"NW)
s
Example 5/75 30 5000 X X Heating fulFii2 X X H 5 5/75 - U NO
Example 7�60 $000 X 8/78 X Ir hlt CASTrichT#79016 ne X X E 7 7/60 U �••
Z 7/78 5 5000 X X HeatingkI�1 #2 - X X H 5/78. U NO
o �.
U
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20. HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? YES 22.CERTIF(CATI certify nder penalty of 144hat I have personallySIGNATURE 22b.DATE SIGNED
■ examined and am fain ith the nformat,on submittla in this and all attached
t 2 1. COMMENTS: documents and that n my i uiry of those indivi+swls immediotely responsible
1 0 m e for obtoinipg the inf ,I belt a that the submrpl information is true, --- - 1�1 Z -,- ..#& -
F.. accurate and complete Ities: y owner who kno+gly foils to notify shall be rpire
LE �/ner u aeasubject fo o c vil penoto exc $10,0D0 for eoch*nk for which notification 22c NAME Type-FN " snot given for wK infor Lon is wbmtte . William R. Lanning Marshal
COPY 2 : SENj4010bAL FIR F.,;MARSHAL r
I
I
DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
Applicatio
TOWN OF SOUTH WINDSOR PERMIT#
e--- BUILDING DEPARTMENT y �'
AJP�rROVED 1540 SULLIVAN AVENUE Bldg. Permit#
AK-'-, 644-2511 ext. 230
Date Buil g Inspector
Application must be printed or typed
FEE SCHEDULE Location of J b:
$0-$1,000=$15.00 Street No. T Street :No.
No.
Over$1,000=
$15.00 per$1,000
or any fraction thereof Tenant Designation A
APPLICANT y�f�Iu l C�J�w iL / 1�/9it/C�� ��iyC _J•t,(__.
APPLICANT ADDRESSIry
s%n
APPLICANT PHONE# Z-6cZ
OWN St OWNER v
OWNER ADDRESS
+ , OWNER PHONE
C = ESTIMATED COST$ `�U4
x IS THIS A CONTRACT COST'? -�es _No
o 0 /�4k;G FEE ENCLOSED$�
r46 ;0 TYPE OF JOB:
R C t�ew Installation
Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
❑RESIDENTIAL BUILDING PERMIT APPLICATION? ElYES ❑NO
❑BSLSINESS CANT USE AND OCCUPANCYj7E-
ASSEMBLY
El❑EDUCATIONAL FUTURE USE AND OCCUPANCY
'T
❑INSTITUTIONAL
❑FACTORY ENGINEER'S NAME PHONE
❑STORAGE
❑GARAGE ADDRESS
❑MIXED USE
`�
(Other please specify) CITY STATE ZIP
TYPE OF INSTALLATION/WIRING METHOD
SIZE OF SERVICE —N SIZE OF MAIN CONDUCTORS
NUMBER OF METERS l NUMBER OF DISCONNECTS AND RATINGS
NUMBER OF PANELS REMOTE DISCONNECT REQUIRED? ❑YES ❑NO
NUMBER OF LIGHT CIRCUITS NUMBER OF POWER CIRCUITS
NUMBER OF SWITCHES NUMBER OF OUTLETS
NUMBER OF LIGHT FIXTURES NUMBER OF HEAT CIRCUITS
NUMBER OF A/C CIRCUITS
SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED.
DESCRIPTION OF WORK
"C iys art/� "1 SOj't�n ,D 3cl L , ir�c�/ 7m
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
CONTRACTORS LICENS O. E STATE
SIGNATURE OF APPLICANT DATE S UJ
UNDERGROUND STORAGE PG Of STATE OFCONNECTICUT ts � EPHM-6 RevS'94 A DATE ENTERED
2' Department of Environmental Protection a! 3 AGENCY USE ONLY
FOR STATE
Q , � � UNDERGROUND STORAGE FACILITIES PROGRAM
FACILITY NOTIFICATION
_ —
i Management Bureau of Waste Mana
Z � 9 < '�:' B FEE BILLED C FEE RECEIVED
O (� FIRST 79 ELM STREET.Hartford,CT 06106-5127
U 1 a. I ' NOTIWATION TEL.(860)424-3374LU f
`-`' SITE I.D. D GRID COORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS
U) OR n 03 1PLEASE TYPE OR PRINT.ALL THREE COPIES MUST BE LEGIBLE X Y YES ❑ NO
NOTIFICATION
b SUBSEvUENN (if checked, p( Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form.
enter no.
SITE NAME NO AND STREET NEAREST INTERSECTING STREET CITY OR TOWN STATE 5 LATITUDE LONGITUDE
LOCATION _ „ I O �� I o
4. OF FACILITY I �QE N�/qTJ 0�A tt�E/2 t //�� TN 0 l � . SO-Tp / C
BUSINESS NAME AND AME NO.AND STREET �- !� ( (;fly OR TOWN STATE, ZIP CODE TELEPHONE
6. MAILING ADDRESS C.. WI NTj Saf kle� �E� �/7,5' ElUA 6 /C M d uTP I�tl�/�S_�� � O6d 741 ( C I Of -r���
ccNAME NO.AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE
zO 7. FACILITY OWNER O �i Q F T / Q /57o S-z I✓A� AV'�i dpNT N N� 5 Oi/L CTj 04674- ( 66) 4 44r_ZS1I
w 8. TYPE OF OWNER PRIVATE L: STATE MUNICIPAL FEDERAL(G.S.A.NO. ).
NAME NO.AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE
OPERATOR/CONTACT d �•-�� c 1y
9. PERSON �✓/l.LIA Arttvr�G ��(� �o S �.rL� 1/Y a ( �(�1 -OS /
10. 11 a. 11b. 12a 12b.STATUS 13 TYPE OF 14.CONTENTS 15.CONSTRUCTION 16 PROTECTION 17.INTEGRAL 18. 19 FAILURE
CONTENTS MATERIALS a.INTERNAL b.EXTERNAL PIPING SYSTEM DETERMINATION
b CONDUCTED?
TANK I.D. DATE OF TOTAL o EST.QUANTITY DATE i CHEMICAL NAME OF PRINCIPAL to o E z z E z DATE OF MONITORING
z N w w w o ¢ to w O o 0 c�O o w J O o 4' o a INSTALLATION SYSTEM
INSTALLATION CAPACITY W z c) LEFT STORED TANK o o SUBSTANCE ¢O_ (It"YES",enter"DATE"
w d rn O¢ 7 r 0 0— w JtSH w�¢ 0 W OH W O. 01- Q•`m iv rN
(Mo./Yr.J r (Gals.) 0 0< (if any) O LAST w o o (not trade name) w c7O rn = H z J Oz w a a zo w = 'N �� w� OR and attach results).
w ? z a i (Gals.) w USED "' (Enter C A.S.No.i1 known) u~i w z a F- " z F O¢ � W p v REPLACEMENT (Specify type (if"NO",enter"NO")
w = ¢Z o� = m-d0 � ¢O O ¢O On ¢�
a- rc (Mo.Nr.) J 0 LL w rn 3 ¢ �t a (Mo./Yr) from list B)
� ¢ a a �
Example 5/75 30 5000 X X Heating fuel#2 X X H 3 H 5/75 U NO
Example 7/60 — 8000 X 8/78 X I,I,I,-Tricloroethane X X E 7 W 7/60 U —
CAS#79016
o -' i f Sooa /o- eta Hr if/�G oft A/0
P
U
W
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I
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20.HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION. _^_ YES
22.CERTIFICATION:I certify under penalty of law that I have personalty examined 22a.SIGNATURE 22b DATE SIGNED
0and am tamdiar with the information submitted in this and all attached documents and that r ^,
Z 21.COMMENTS: based on my inquiry of those individuals immediately responsible for obtaining the information, X
��/ V / I believe that the submitted information is true,accurate and complete. --
//y l E• r a�r 22c.NAME(Type arms) 2d.OFFICIAL TITLE(of owner or authorized
U �f/ Penalties:any owner who knowingly fails to notify shall be subject to a civil penalty not to p - representative)LLj .
Cn
L/` D exceed 51 0 OOG for each tank for which notification is not given or for which false information L�14L A M R A^( ///t r ��/F• ,.r
�7 nJ is submitted.
COPY 2. SEND TO LOCAL FIRE MARSHAL
UNDERGROUNDSTORAGE PG of l STATE OFCONNECTICUT EPHM-6 Rev5r94 FOR STATE A DATE ENTERED
2. Department of Environmental Protection �-Voxi' 3. AGENCY USE ONLY
FACILITY NOTIFICATION UNDERGROUND STORAGE FACILITIES PROGRAMZ i� , Bureau of Waste Management " B FEE BILLED C FEE RECEIVED
O �"'� FIRST 79 ELM STREET,Hartford,CT 06106-5127 °�
V la. I I�NOT (CATION TEL.(860)424.3374
w SIT I.P. r D GRID COORDINATES E DOES FACILITY MEET NEW REQUIREMENTS?
( OR PLEASE TYPE OR PRINT.ALL THREE COPIES MUST BE LEGIBLE �/ �/
17(! SUBSEQUENT (if checked. `� A i ❑YES ❑ NO
b IL-7 NOTIFICATION enter no.) Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form.
LOCATION SIT�ME �.�.- NO AND STREET I NEAREST INTERSECTING STREET CITY OR TOWN / STATE 5.LATITUD 9 LONGITUQ/E�J
4. OFFACtLITY ��c'/� ��t��Q � f�tZ( J�lrs ��7�r ���/^G'Gr+/ �tr, f'GS// !: /�d s�.,'rH �rl//./ r2 CT �'I� ' / �O rr iZ�JT r�57 r
BUSINESS NAME AND NAME _ NO AND STREET CITY OR TOWN STATE ZIP C/ODE TELEEPHONE/'y
6. MAILING ADDRESS S� �trY{� S�R /fir_ (��` ,�� //7S' GG��/✓( l�..t /��� �c:v�� ��/r/i7jc/L kT d�iQ7Q (�t6 ) G�77 �S'� 7
a] NAME / NO AND STREET C Y OR TOWN / STAT ZIP CODE TELEPHONE
O 7 FACILITY OWNER ��/ ' t3f St( ( f� L�/l`�i �C9Z �S�G �jct� �11/l�n� ,9�/r, Crtf �l,/�/TiSD(Z �tt+C7� (CftOG )CtrQ� 'ZS��
U
w 8. TYPE OF OWNER i El PRIVATE El STATE MUNICIPAL ❑ FEDERAL(G.S.A. NO. ).
N OPERATOR/CONTACT NA E NO AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE
M J/`t/�r� 4�,\y,A/ \ c�µT ary 9,/ C 5"
9. PERSON V L //iS 'r/L��GT� �� - 1�//vV (L CT Q� /f ( pGC� e19 O
10. 11a. 11b. 12a. 12b.STATUS 13 TYPE OF 14.CONTENTS 15.CONSTRUCTION 16.PROTECTION 17.INTEGRAL 18. 19.FAILURE
CONTENTS MATERIALS a.INTERNAL b.EXTERNAL PIPING SYSTEM DETERMINATION
b. CONDUCTED?
TANK I.D. DATE OF TOTAL EST.QUANTITY DATE c~� CHEMICAL NAME OF PRINCIPAL U LC U' z z E g n z DATE OF MONITORING
z N uJ i p m w o p U O U O o �-o oia
INSTALLATION _ CAPACITY w z U LEFT STORED w TANK ¢o Q o SUBSTANCE a U v o w INSTALLATION
o w o o 8 U J SYSTEM (If`YES".enter`DATE
c.� .� rn O a i > r-o U_ w .�2 i- w < w z O ui W O- O U w >.m
(Mo./Vr) w (Gals.) o (If any) O LAST W g o (not trade name) w t0 O rn =.� z =w ~a a =w =. N E- OR and attach results).
z a l (Gals.) w USED _ (Enter C.A.S.No.,if known) In w z a p o� -1 z <O O m a O o nJ z� o� REPLACEMENT (Specify type (If"NO",enter"NO")
m z i cr (Mo.Nr.) O J 0 m¢ m U cc V CL a N �� a- (Mo./Yr.) from list B)
Example 5/75 30 5000 X X Heating fuel#2 X X H 3 H 5/75 U NO
Example 7/60 - 1 8000 X 8/78 X 1,1.1•CAs# methane X X E 7 W 7/60 U -
i --
U 7 78 1.s Soioo 4 owc o It X )4 /�lv
O
U
W
20.HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? I` YES 22.CERTIFICATION:I certify under penalty of law that I have personally examined 22a.SIGNATURE 22b DATE SIGNED
and am familiar with the information submitted in this and all attached documents and that
Z 21.COMMENTS: X
based on my inquiry of those individuals immediately responsible for obtaining the information, �7•�,/
I believe that the submitted information Is true,accurate and complete
22c.NAME(Type or Print) 2d.OFFICIAL TITLE(or owner or authorized
U -.�; ` w Penalties any owner who knowingly fails to notlty shall be subject to a civil penalty not to n representative).
w �/j �/L/" J „J rY ,Ta G r U exceed S10 000 for each tank for which notification is not given or for which false information 1 ( /A/� K 1�I
U) L H
is submitted. r'�
COPY 3. RETAIN FOR YOUR RECORDS
apartment of Environmental Protection EPHM•6 NEW 10/85 A SITE I.D.
OUND STORAGE FACILITIES PROGRAM 3. FOR STATE
RDOUS MATERIALS MANAGEMENT UNIT AGENCY USE ONLY
5 Capitol Avenue,Hartford,CT 06106
g,DA IE V p.E.P C.DATE ENTERED
TEL.5564630 8 6
►E.ALL THREE COPIES MUST BE LEGIBLEI Y" D.GRID COORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS?
i FOR FILING NOTIFICATION before completing form. SIB 400 X YJ ❑YES ❑NO
ET NEAREST INTERSECTING STREET CITY OR TOWN STATE t}IIO��p r 310 r' 1 7E. �7 0 LONGITUDE
5 1 J
South7
JET CITY OR TOWN STATE ZIP CODE TELEPHONE
llin ton Rd.' South Windsor (2n3L-644-8547
ET CITY OR TOWN STATE ZIP CODE TELEPHONE
llivan Avziiue South Windsor' Q6074 (2'03i�644-2511 FEDERAL(G.S.A.No.
ET CITY OR TOWN STATE ZIP CODE TELEPHONE
lli,ngton' F.d. South Windsor Ct19wiLrAd-8547
14. CONTENTS- 15.CONSTRUCTION I&PROTECTION 17.INTEGRAL
MATERIALS IN RNAL b.EXTERNAL PIPING SYSTEM 18. 19.FAILURE
CHEMICAL NAME OF PRINCIPAL 0. b.DATE OF MONITORING DETERMINATION
SUBSTANCE w W < v 0 �Cl V Z Z INSTALLATION
V rrs o o,= o o_ .; 4 a y SYSTEM CONDUCTED.
(not trade name.) L ; _'o_ w =w Lu ILa O u ='a,- i W OR (If'YES'.enter DATE"
(Enter C.A.S.Noylf known) w W Z d ~a E w s t p a= a E -K r < REPLACEMENT (Specify typ )
w m w O`a Z Z Q O Q O O!° Z a and oHoch results).
N ss: V a V 3 U •� O o `^ (Mo./Yr.) from Lst B) If"NO',enter'NO')
Heating fuel#2 X X H 5 5/75 U NO
I,l/lr-Trichlo e X �//� C L 7 7/LV O U
CAS N79016 9016
Beating Dil #2 X I X B 5/78 U NO
fro
c>aeat Gast i,
22.CERTIFICATION: I certify under penalty of law that I have personally 22a.SIGNATURE 22b.DATE SIGNED
examined and am familiar with the information submitted in this and all attached X.� /� j
documerMs and that based on my inquiry of those individuals immediately responsible (//('J/
for obtaining 1M information,I believe that the submitted information is true, � pr] L?��9 R ti
accurate and complete.Penalties:any owner who knowingly fails to notify shall be —Mrc,Al TITLE(ol owner or authorized
subject to a civil penalty not to exceed$10,000 for each tank for which notification 22c.NAME(Type or Print) representonve).
is not given or for which false information is submitted William R. Lanning Fire Marshal
SEND TO DEP: 165 CAPITOL AVE. HARTFORD, CT 06106
1��A
1
UNDERGROUND STORAGE IPG,I of I STATE OF CONNECTICUT
Department of Environmental Protection
FO�ILITY NOTIFICATION 2 , / UNDERGROUND STORAGE FACIUTIES PROGRAM
HAZARDOUS MATERIALS MANAGEMENT UNIT
Z 165 Capitol Avenue,Hartford,CT 06106
O FlRSt -. -_
H lo. NOTIFICATION TEL.556-4630
SIT /
vU OR D.
LL'i V PLEASE TYPE ALL THREE COPIES MUST BE LEGIBLEI
SUBSEOUENT (If checke . `J
b ❑ checked
. I enter No.) Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form.
LOCATION SITE NAME NO.AND STREET NEAREST INTERSECTING STREET
4. OF FACILITY
BUSINESS NAME AN N M NO,AND STREET
6. MAILING ADDRESS $o. Windsor FiXeL De t. L175 Ellington Rini.,
m NAME NO.AND STREET
z 7. FACILITY OWNER Town of .south Windsor 54Q Sullivan AvWme
s-
❑ PRIVATE ❑ STATE MUNICIPAL
H 8. TYPE OF OWNER ❑ FEDERAL(G.S.A.No.
OPERATOR/CONTAC1 NAME NO.AND STREET
9. PERSON William R. Lannin5 1 -1175 Ellin(iton T-d.
10. 110. 1lb 12a. 12 b. STATUS 13. TYPE OF 14. CONTENTS 15.CONSTRUCTION
DATE CONTENTS MATERIALS
DATE OF i— TOTAL p I EST.QUANTITY F CHEMICAL NAME OF PRINCIPAL
TANK 10. U
INSTAIIATIO I u e CAPACITY Z U I LEFT STORED p TANK . Q SUBSTANCE n W
(Gals.) O a > LAST O v (not trade name.) 1- w
(Moe/Yr.) x o N Z a I (if any). O USED a s f o (Enter C.A.S. No. If known) w 'z `
uW,'= m? I (Gals.) w ?� Mo No,
m-0 0,
z a I o (MO./Yr.)
Example 5/75 3015000 X X Heating fuel#2 X
Trorcieth
Example 7/60 8000 X 8/78 X Lr I,It.CASI#79016 one X
z
7/78 5 500a X X creating ' 3il #2 X
0
P
U
W
U
L' l�
AY 619 6
s�ta:er is tQa peat tint
RAKI
FOR
I
20. HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? YES 22.CERTIFICATION: I certify cruder penotty of few that I have
0 examined and am fonvTtor with the Wo n otien submitted in thin and
z 21. COMMENTS: documents and that bared an my itulu y of*oose individuals immedio
0 for obtaining/M information,1 belie-that the sabmflted information
Uaccurate and complete.Penalties:any owner who knowingly fails to,
tL subject to a civil penalty rat to exceed S10.00D far each tank for whit
N is not given or for which false infantwtion a
UNDERGROUND STORAGE PG or STATE Of coNNECTICtJT EPHM Rev.594 FOR STATE
2. Department of Errvitrorlrnent!�41=
3. AGENCY USE ONLY A DATE ENTERED
FACILITY NOTIFICATION I / I / 1 UNDERGROUND STORAGE F Cc�aAM
I / I r �
Z, Bureau of Waste Man& B FEE BILLED C.FEE RECEIVED
0 79 ELM STREET,Hartford.CT 061W5127
FIRST
W1a. ❑ NOTIFICATION TEL.(SM)424-3374
SITE I.D. D.GRID COORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS?
O CO 2 :1 PLEASE TYPE OR PRINT.ALL THREE COPIESMUST BE LEGIBLE V V
b SUBSEQUENT (if checked, J 6 \\ Refer to INSTRUCTIONS FOR FILING NOTIFICATIOy before completing form. ^ i ❑YES ❑ NO
NOTIFICATION enter no. r7 +Ja
LL- TW
4. OF FACILITY . . ONGITUDE
LOCATION � /A a �E/�.� �u t �,7/_lZ .5 ME !I 7.5�G LL/!�(GTo^/ � NEARED ,►A�IN(i 4 ' CITY OR TOWN STATEI�� W/ND.50rL �r S.LATITUDE .. 17
o J"! . 6i ..
O BUSINESS NAME AND NAME NO.AND STREET �/l� CITY OR TOWN TATE ZIP CODE TELEPHONE
6. MAILING ADDRESS SO. W1,V D sc 2 t,f k ��� /7� fL4nl�sir d Sc��1i ��A/D so 2 C O 6 G`�¢ ($�,v) 6�q FS S�7
Z t9 r NO.AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE
Q o ER 1d n� dF �auTH V,A/a9 �ec- 1�¢b S�L�.CI�Ip/,c f}1lF Sc,�-ttt 1�Irr7J�6li 7� 060?4 (g66) �44�Z5"/�
L) ❑ PRIVATE ❑ STATE MUNICIPAL ❑ FEDERAL(G.S.A.NO. )•
U W B.TYPE OF OWNER
W �! OPERATOR/CONTACT NAME n NO.AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE
'^ 9.PERSON WiL C)p M of C , ( )
v, v. 11a. 11b. 12a. 12b.STATUS 13 TYPE OF 14.CONTENTS 15.CONSTRUCTION 16.PROTECTION 17.INTEGRAL 18. 19.FAILURE
�,.
J CONTENTS MATERIALS 6.INTERNAL b.EXTERNAL PIPING SYSTEM DETERMINATION
J s b. CONDUCTED?
Q TANK I.D. DATE OF i TOTAL 0 t EST.QUANTITY o I DATE c~i CHEMICAL NAME OF PRINCIPAL w E U O o 0 0 o zo 9 Z_ DATE OF MONITORING
INSTALLATION a CAPACITY w z I LEFT STORED w TANK Q c <a SUBSTANCE <O ¢9 o w o t't o t= ¢— om INSTALLATION SYSTEM (if"YES',enter"DATE'
W y O I > o— w J¢ w < w Z o c) w° O 0 w ,m =73 u^ OR and attach results)-
(MolYc) (Gals.) o g (If any) o LAST w (riot trade name) w ¢O J = N z Zi =w !, =w x=H ¢— w�
W: z Z I (Gals.) , USED _ (Enter C.A S.No.,rf known) ini w z a p �aJ a p o a p p aJ W Qy REPLACEMENT (Specify type (it"NO",enter"NO")
W LL to I (Mo.Nr.) o f 0 CD Q m 0 a 3 0 cc � �� a (MoJyc) from list B)
—J Example 5/75 30 5000 X X Heating fuel k2 X X H 3 H 5/75 U NO
C
2 i� Example 7/60 — 8000 X 8178 X 1,1'I,CAS to ethane X X E 7 W 7/60 U —
0 1
01
z_ i o
' U
IL w
Cc
i
W
CL
I
W
ll.l � 20.HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? ❑ YES 22.CERTIFICATION:I certify under penalty of ersona law that I haw psy examined
22a.SIGNATURE 22b.DATE SIGNED
� ! ZO 21.COMMENTS T �Q and am familiar with the information submd W in this and al attached dorvntents and that Q
I.L. 'C f� J! �r A C {t�b/4 C L- basae«t my:rou:y a tMae in6vidwla.m>�arMy�po�hr ar otxaktirq me inbrmati«,. X E dt�A fC�/
n
I believe ChM all autxrtieed information is true.aoaaase and compiMa. 22e.NAME(Type or Print) 22d.OFFICIAL TITLE(of owner or authorized
W Penalties:any owner who knowingy,fails to notify shall be subject to a civil penalty not to representative).
(n exceed S t QAW tersa; tank for which notillcaYa+is not given or for which false information
is submitted.
Wfl.114 M �. 4 Ate•PIn(6 f',ftt� �f��S//g4
i CO P
i 1 . SEND TO DER:79 ELM ST.HARTFORD,CT 06106
Electric # APPLICATION FOR BUILDING PERMIT
Plumbing#HVAC # 1175 Ellington Road
Sprinkler# 31128 Estimated Cost $�
FINAL ROV - - I
Building�l 1 0y � � _ — -- - Permit Fee $
En nngi COMPLETE RED BOXED AREAS Occupancy Fee $
Engineeavit g TYPE OR PRINT ONLY Eng. Insp. Fee $
AffiAppr. for CO. SIGN ON REVERSE SIDE Total Fee $Lt- u,ued
TO THE BUILDING DEPARTMENT,TOWN OF SOUTH WINDSOR, CT (Additional Cost) $
The undersigned hereby applies to do work according to the following: IJ cd/
Applicant `'� r�� c Location of Work Lot No.
Applicant's Address 7 Y ^ J'T— Tel.# ?e o
Town i � Zip C� %O� Lic.# S 9 S/
Owner '-mac— Architect
Owner's Address Architect's Address
Zip Zip
Sq. Ft. New Area: 1 st FI. 2nd A. a 3rd FI. P Total New Area
Purpose of this permit ti° '`�-,rti "� 1 oev F-4 a' ndr..P
0
City Watero Wello Septic System❑ Sewer❑
Ins: HO P. ert. Area Basement Garage
Approved b ate 6 Use Gro y �"tuction Type
Revised 6f02
01
I hereby agree to conform to all the requirements of the laws of the a of Connecticut and the Ordinances of the Town of
South Windsor and to notify the Building Inspector of any alt the plans or specifications of the Building for which this
permit is asked,and agree that this building is to be located distance from all street lines,side yard lines,and required
distances from all other zones and is k)cated in which this ng and its use is allowed.
Signed
I hereby apply for a Certificate of y for the work described in this application for the permit.
Signed
DO NOT WRITE BELOW THIS LINE
INSPECTION COMMENTS
Inspection / Approval Date By Appl
Code Description Due Whom Code Comment
-------------------------------------------------------------------------------
**-31128-B 135,649 •
B10 FINAL 11/14/08 JFF A
DEPARTMENT DECISION APPLICATION FOR ELECTRICAL PERMIT
(I M TOWN OF SOUTH WINDSOR PERMIT#
Application is hereby: D � ((7 � u U r
v U U f
BUILDING DEPARTMENT
APPROVE MAR 2 0 2008 1540 SULLIVAN AVENUE
Bldg. Permit#
644-2511 ext. 230
->O• CA;f 41 South Windsor
Date Building In r BUILDING DEPARTMENT
Application must be printed or typed
FEE SCHEDULE F-
APPLICANT
_ Location of Job:
$0-$1,000=$15.00 treet Lot No.
Over$1,000=
$15.00 per$1,000or any fraction thereof gnation Apt.No.
APPLICANT ADDRESS
APPLICANT PHONE# L C L
�0W N Sf4 OWNER
OWNER ADDRESS
U7 a OWNER PHONE
C = ESTIMATED COST$
IS THIS A CONTRACT COST'? _Yes _Nam—o— '
tom, o e( '/4CJ FEE ENCLOSED$ A1y Q
�OSOR•CO�� TYPE OF JOB:
New
Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR ELECTRICAL PERNUT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? O YES O NO
❑RESIDENTIAL
❑BUSINESS CURRENT USE AND OCCUPANCY
❑ASSEMBLY
0 MERCANTILE FUTURE USE AND OCCUPANCY
❑EDUCATIONAL
❑INSTITUTIONAL
❑FACTORY ENGINEER'S NAME PHONE
0 STORAGE
❑GARAGE ADDRESS
❑MDCED USE
CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATION/WIRING METHOD
SIZE OF SERVICE SIZE OF MAIN CONDUCTORS
NUMBER OF METERS NUMBER OF DISCONNECTS AND RATINGS
NUMBER OF PANELS REMOTE DISCONNECT REQUIRED? ❑YES 0 NO
NUMBER OF LIGHT CIRCUITS NUMBER OF POWER CIRCUITS
NUMBER OF SWITCHES NUMBER OF OUTLETS
NUMBER OF LIGHT FIXTURES NUMBER OF HEAT CIRCUITS
NUMBER OF A/C CIRCUITS
SEPARATE HEAT LOSS AND A/C CALCULATIONS MUST BE SUBMITTED.
DESCRIPTION OF WORK
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFgRMANCE OF SUCH WORK.
CONTRACTORS LICENSE NO. TYPE STATE y
SIGNATURE OF APPLICANT DATE
DEPARTMENT DECISION APPLICATION FOR PLUMBING PERMIT
TOWN OF SOUTH WINDSOR PERMIT#
Applic is y � Z�
BUILDING DEPARTMENT
D 1540 SULLIVAN AVENUE Bldg. Permit#
644-2511 ext. 230
Date kpildiEg Inspector
Application must be printed or typed
FEE SCHEDULE Location of Job:
FTenantDesignation
e �L i,VG7,0,y 176)AP
$0-$1,000=$15.00 Street LotNo.
Over$1,000$15.00 per$1,000
or any fraction thereof Apt.No.
APPLICANT J ,C�f��J!� 2c� ! S j►/�� .G�/
APPLICANT ADDRESS 2 O
So
APPLICANT PHONE# LV 47d d )
0%4 N St OWNER O w N o S , 2.J S C5 1JIc-'o/
OWNER ADDRESS 117 LPL !Y�r7 O N uf}A
+ OWNER PHONE
C ESTIMATED COST$ ZOO D
* IS THIS A CONTRACT COST? _Yes No
l� o �CJ FEE ENCLOSED$ 4
SO- O,/�� TYPE OF JOB:
R C New Installation
_Alteration/Addition/Repair
Revised 4/01//2002
APPLICATION FOR PLUMBING PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
❑RESIDENTIAL
BUILDING PERMIT APPLICATION? ElYES ❑ O
,,//
El BUSINESS CURRENT USE AND OCCUPANCY 1 /7r !�`d
❑ASSEMBLY �! �'�l
❑MERCANTILE FUTURE USE AND OCCUPANCY
❑EDUCATIONAL
❑INSTITUTIONAL
❑FACTORY ENGINEER'S NAME PHONE
❑ STORAGE
❑GARAGE ADDRESS
❑MIXED USE
CITY STATE ZIP
(Other please specify)
TYPE OF INSTALLATION SIZE OF MAIN DRAIN
NO.OF TOILETS STYLE NO.URINALS STYLE
NO.OF BATHTUBS NO.OF SHOWERS NO.OF LAVATORIES
NO.OF CONDUCTORS SIZE NO.OF STACKS SIZE
AREA OF ROOF NO.OF CATCH BASINS NO.OF FLOOR DRAINS
NO.OF OTHER FIXTURES KIND
ARE TOILET COMPARTMENTS VENTILATED TO OUTER AIR BY A WINDOW ❑YES ❑NO
SIZE OF WINDOW IF NONE C.F.M.OF VENTILATOR
SIZE OF DUCTS SEWER OR SEPTIC TANK
SIZE OF WATER MAIN SIZE OF WATER PIPING&RISER
WATER HEATER: TYPE MANUFACTURER
DESCRIPTION OF WORK
% /y c7`/aL L �} /I/) /?o X / 06 , 0 F 7 ��f 4Z-THE UNDERSIGNED HEREBY APPLIES FOR A PER IT TO PERFORM THE WORK DESCRIBED
l�
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
0 ZZ V5- P /
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE 2-08
s
c y�
C
APPLICATION FOR ELECTRICAL PERMIT
TOWN OF SOUTH WINDSOR BUILDING DEPARTMENT
1540 SULLIVAN AVENUE SOUTH WINDSOR, CT 06074 (PHONE) 860-644-2511 EXT. 230
DEPARTMENT DECISION PERMIT NUMBER
APPLICATION IS Y: I U V y
`/ BLDG.PERMIT NUMBER:
G(J
DATE OR
LOCATION OF WORK: J 6e,G/N&7-bA)
APPLICANT: OWNER: TYPE OF STRUCTURE:
K�t.11 0 C44 ti-f bV, ) d L
Q �, `^ L��� � J (�p p E NEW BUILDING
NAME: BILL)g rl I�D C�-�L� t L NAME:�l""� ��/•C "`r I. zi ADDITION
PHONENUMBER. ���� � PHONE NUMBER: £��I^S�ti WfXISTING BUILDING
ADDRESS: 182 0,+ILW OO a Dr• ADDRESS: S. LJ--J�sQY 6 C7 -
TYPE OF USE:
d4p033
RESIDENTIAL se01v4v1ERCLAI
ELECTRICAL INFORMATION: FURTHER DESCRIPTION OF WORK:
TYPE OF INSTALLATION: 1 AJ&i*1 Ate" 1- � [.&V O "-J c/v 7 �l��/✓s
SIZE OF SERVICE: _ /b ALe4d E'e'A.0/dU✓ /� e o'- 5 14 V
SIZE OF MAIN SERVICE:
NUMBER OF METERS:
NUMBER OF PANELS: _
NUMBER OF LIGHT CIRCUITS: _ ESTIMATED COST:S L �a
NUMBER OF SWITCHES:
NUMBER OF LIGHT FIXTURES: FEE ENCLOSED:S
NUMBER OF A/C CIRCUITS: C'A g 4
FEE SCHEDULE:S18 PER$1,000 OF THE ESTIMATED COST.
NUMBER OF POWER CIRCUITS: ROUND UP TO THE NEXT THOUSAND ONCE THE PROJECT
\UMBER OF OUTLETS IS SI.00 OVER. (26 CENT EDUCATIONAL FEE INCLUDED AS
PART OF THE PERMIT FEE)
THE UNDERSIGNED NEARBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO COMPLY WITH ALL LOCAL
ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE PERFOMANCE OF SUCH WORK.
CONTRACTORS LICENSE NO.: IZ 35 1PK _ TYPE: �= ( STATE: C '
SIGNATURE OF APPLICANT:T_�� �, l— DATE:__��21 !C}
Lum nai ire Schedule
Symbol Oty Label Arranaernent LMF Lum.Lumens Lum.Watts Part Number
1 PWY-5M SINGLE 0.980 1666 22 PWY-EDG-5M-P4-02-UL-BZ-350-40K
1 B-WSN SINGLE 1.020 11478 86 OSO-A-NM-WSN-B-40K-UL- w/OSO-AA-_
o- 2 B-5M SINGLE 1.020 10867 86 OSO-A-NM-5ME-B-40K-UL- w/OSQ-DA-
14 B-4M SINGLE 1.000 8779 86 0SQ-A-NM-4ME-B-40K-UL-_w/OSQ-DA-_
Calculation Summary(Footcanciles calculated usina prodk`ted hmen values0 50K hrs of on
Label _ Units _ Avg Max Min I A Min I Max/Min
2nd Lot Fc 0.95 3.5 10.1 19.50 135.00
Main Lot Fc 2.46 16.2 10.3 18.20 120.67
-CUSTOMER TO VERIFY ORDERING INFORMATION AND
CATALOGUE NUMBER PRIOR TO PLACING ORDER
-Mounting Height=MH
Required Mounts:
(16)OSO DA-_
(1)OSQ-AA--
4 1
2.6 3.8 3.6 2.5 2.1 1.1 1.5 2.9 3.1§3.6 ...S 2.t 1.2 0.9 1.4 2.9 3.1 0.1 3.0 2.9 -4 2.1
2.7 3.4 3.1_3;0 9 1.1 1.4 2.8 3.8 3.6 B�5 11.5 1.4 1.1 1.5 =.9 3.7 3.5 �2.tl _'.7 3.5 #'
MH:18
2.2 1.4 ..9 2.2 2.1 1.1 1.6 2.9 2.8 2.9 .1 3.0 1.7 1.5 1-9 3.2 2.9 3.0 3.1 3.2 1.8 1.3 1.0 0.8 0.8 1.0 1.6 1.9 2.7 B4M
1.0 1.1 1.1 1.1 1.3 1.4 2.1 2.2 2.1 2.3 1.6 3.2 2.6 1.8 2.4 3.0 2.9 2.5 2.3 2.4 2.5 2.0 1.4 1.2 1.2 1.4 2.0 1.7 MH:18
0.6 0.8 0.9 0.8 D.e 1-0 1.9 2-8 2.7 2-9 3.3 4.5 2.9 2-6 L.f 3.8 4.0 3.0 2-8 2.7 2-9 1.7 1.9 2.1 2.3 2.2 1.5 1.5
}
- 0.5 0.6 O.f 0.6 0-9 3.] 4.1 1.0 4.2 3.5 3.9 4.1 4.2 4.1 3.5 3-8 2.5 ..7 „IS.2 2.2 1.1 1.0
- 0.5 0.6 0-7 0.7 =4., 3.4 4.4 3.4 1 3.9 4.1 4.1 4.11- 3.0 2.] 1.8 B.SM 1.3 1.0
B-4M B-4M B-4M Main Lot W-48.7
1.3 1.7 1.8 1.3 1.8 MH:18 MH: 18 MH:18 2.f 2.4 2.4 2-3 1.4 0.8 0.5 - ..
u, x 2.2 3-0 2.0 2.1 3.0 2.9 3.1 3.2 1.8 1.3 0.9 0.6
3.6 4.2 5.6 S.. 4.2 E 4.1 2.7 1.8 1.5 1.1 D.0
3.1 "-
5.a E.2 6! 5.6 I 3.tp.44 JA2.7 2.0 2.3 1.6 1.5
2.d T 6F �_
7rS4.y+.i MH' 1.(0 .1 2.6 3.3 2.6
B-4M B-4M _
'`�- 2.4 2.3 2.5 2.6 2-3 3.3 3.6
MH:1>sIIH: 18 �s_�•r Tr.,._'-�..�,..:
2.3 2.2 2.4 2.7 2.4 2.9 3.8
B-0
{0�(-Ce_ •.+f a _ f+- - , 3.3 3.2 3.3 2.3 2.2 3.8 2.6
+-•�F 4 i_ 3.7 4.2 2.8 2.2 2.7 2.6 2.6 MH: 18
3.9 4..0u 2.9 2.3 2.3 1.9 1.7
0� B--l111 e,
e 3. 4 3 2 2.2 2.7 2.4 2.5
2.9 2-6 2.4 2.4 2.4 3.7 7.7
L.,-- "M 2.0 2.0 1.0 2.5 2.5 3-0
` 3.0 2.8 2.9 2.5 2.3 3.2 3.7 B-4M
B-WSN � o MH:18��i1
3.0 3.3 3.3 2.0 2.7 3.3 2.7 MH:18
MH: 18 PWY-51111
MH.3.5 - -30 3.0 2.6 2.0 2.3 1.6 1.5
3.$jW.7 1.6 1.2 0.8 0.7
2.9"'JS 1.4 0.7 0.5
- 1.1 1.2 0.6
4Yn..4.+�►r...m 9.pry
CREE= LIGHTING Project Name: 1175 Ellington Rd., South Windsor, CT Layout By:Ben Foste Scale =25
A C0V�ANV 0: IDEAL INDUSTRIES,INC. "'""`""""�"' SR-15865 II Footcandles calculated at grade II Filename: 160701GP1TDLR5.AGl 0 50 -100
�.�1 � 9
MI9,�.,-�»1 �153.96 .-6r.q--(M�2> .., , ...d Date:7/31/2019
101 -.Wm
-� �►--0.75• REMOVABLE 18-, r�--4•Dla p ALUMINUM POLE SHAFT SPECIFICATIONS
REMOVABLE TOP CAP
TOP CAP 16' REMOVABLE T6 TEMPER.N AVAILABLE IN. 5D.188,AND.250 WALL THICKNESS.3-T6 ALUMINUM ALLOY ARE TUBE TREATED TO
TOP CAP
DRILLED PER FIXTURE Mr 4.00•SO. 14' ANCHOR BASE: CAST FROM A356 ALUMINUM ALLOY AND HEAT TREATED TO T6 TEMPER.
' REQUIREMENTS: 2 BASE PLATE AND SHAFT ARE CIRCUMFERENTIALLY WELED TOP AND BOTTOM.
12' THE ANCHOR BASE IS PROVIDED WITH SLOTTED HOLES.
O DM19 -DRILLED 1 90' SEE
VARIES DM28 -DRILLED 2 Q 180' SCHEDULE ANCHOR BOLTS: FABRICATED FROM CARBON STEEL BAR WITH MINIMUM-YIELD
DM29 -DRILLED 2 Q 90' *10 3 STRENGTH OF 55,000 PSI, GALVANIZED,PER ASTM A-153. EACH ANCHOR BOLT IS
DM39 -DRILLED 3 Q 90- FURNISHED WITH TWO HEX NUTS AND TWO FLAT WASHERS.
DM49 -DRILLED 4 @ 90' 8'
�- 4 BASE BOLT COVER: TWO PIECE SQUARE COVER PROVIDED WITH S304 STAINLESS
STEEL HARDWARE.
4.00'SO. POLE SHAFT I 5 GROUNDING: PROVISION;3/8-16 THREADED STUD WELDED TO INNER SHAFT WALL
OPPOSITE HAND HOLE. FLAT WASHER AND HEX NUT PROVIDED.
HAND HOLE: REINFORCED 3"X 5"HAND HOLE IS LOCATED 18'ABOVE BASE. COVER
DRILLED MOUNT STYLES ANCHOR BOLT 6 AND ATTACHMENT HARDWARE PROVIDED. LOCATION AT90 DEG.FROM DRILLING.
c 7 HARDWARE: S304 STAINLESS STEEL.
TENON MOUNT P LE
STANDARD STYLES: HEI HT 8 TOP CAP: REMOVABLE TOP CAP PROVIDED WITH DRILL-MOUNT POLES.
PT23 -2} O.D.X 4- BOLT FINISH: TGIC THERMOSET POLYESTER POWDER COAT FINISH IS ELECROSTATICALLY
25V PT27 -2{'O.D.X 4" PROJECTION 3.00 X 5.00 APPLIED AT A 3.0 MIL NOMINAL THICKNESS. A FIVE STAGE METAL PRETREATMENT
-OTHER SIZES HAND HOLE 9 PROCESS AND SEALER PROVIDE MAXIMUM CORROSION RESISTANCE. THE POWDER TOP
AVAILABLE- W/COVER COAT IS BAKED IN EXCESS OF 400 DEGREES FOR SUPREME ENDURANCE.
SEE ACCESSORIES P LE POLE DIMENSIONS
CUTSHEET« �. HEI HT
F. POLE HEIGHT FT. TOP SQ.SIZE IN. BOTTOM SQ.SIZE IN. WALL THICK.MOUNTING HT. FT.
.25 THK TENON MOUNT PER POLE SCHEDUL 4.00 4.00 .125 PER POLE HT
BASE PLATE DIMENSIONS
•• BOLT CIRCLE IN. BASE PLATE DIM. IN. BOLT HOLE IN. PLATE THICKNESSIN.
3.00 X 5.00 PER POLE SCHEDULE 10.00 SO. PER SCHEDULE 0.75 ■
■ POLE SHAFT EMOVABLE BASE COVER HAND HOLE ANCHOR BOLT DIMENSIONS
• 18 00" W/COVER ANCHOR BOLT DUI. IN. ANCHOR BOLT LENGTH IN.
4.00'SO. 0.75 PER SCHEDULE
REMOVABLE ALLOWABLE WINDLOADING(SQ. FTT.
' : •, 4.00" BASE COVER SEE ENGINEERING DATA SCHEDULE
TENON MOUNT STYLES I / 18. " ^DESIGN CALCULATIONS ARE BASED ON SUSTAINED WIND FORCES PLUS ADDITIONAL 1.3 WIND GUST-
0.00"so. BOLT PROJECTION
a.0o STANDARD COLORS AND FINISHES
12.00"Su "OTHER COLORS AND FINISHES AVAILABLE - SEE ACCESSORIES CUTSHEET-
. . ABOVE GRADE 12.00"sO.� b�MINIMUM........3 POLE AXONOMETRIC POLE ELEVATION p•■,rkI e
MAXIMUM........3 t" I Woks1 125" DBZ(dark bronze) BLK(black) WHT(wade) GRY(grey) GRN(green) ANOD(anodized)
1.875'<p4WSO
�
ENGINEERING DATA SCHEDULE CATALOG POLE SCHEDULE MOUNTING OPTIONS FINISH
MAXIMUM EPA-SQ.FT NO. AVPL-SSA - 4"SQUARE STRAIGHT ALUMINUM SERIES 1Q90 2Q180 2Q90 3990 4@90
SLOTTED MAX. 100 MPH 90 MPH 80 MPH 70 MPH POLE SHAFT WALL BOLT ANCHORAGE O, O'O C� STANDARD
9.50"&10.25" FIXT.WT. HEIGHT SIZE THICKNESS CIRCLE
DIA.BOLT
CIRCLE 100 12.4 15.9 20.7 27.6 84-125 B' 4"X 4" .125 10} 3/4"X 18"X 3' DRILLED TENON ARM STYLE DBZ
10.25'DIA l^�\ (SEE 100 8.4 11.3 14.8 20.2 104-125 10' 4'X 4• .125 10}' 314"X 18"X 3" DM19 (1@90') PT23 SPECIFY BLK
9.50'DI h J' SCHEDULE) 100 5.6 7.7 10.7 15.1 124-125 12' 4"X 4" .125 1041 3/4"X 18•X 3' DM28 (2Q180°) (2t O.D.X4") (SEE ARM WHT
DM29 (2@90°) CUTSHEET GRY
100 3.5 5.2 7.7 11.4 144-125 14' 4'X 4" 125 10}" 3/4'X 18"X 3' PT27 GRN
100 2.0 3.4 5.4 8.4 164-125 16' 4"X 4• .125 10}' 314"X 24"X 3" DM39 (3090') SPECS)
DM49 (4�90°) (�O.D.X4")
■ 100 WA 1.9 3.7 6.4 1W125 19 4'X 4' .125 10}• 314"X 24-X 3' OTHER: OPTION:
AL-4 TEMPLATE (SPECIFY) ANOD
SERIES POLE SHAFT WALL MOUNTING OPTIONS FINISH ACCESSORIES OPTIONS
10.00 X 10.00 X.75 ANCHOR PLATE ORDER LOGIC: HEIGHT SIZE THICKNESS DRILLED/TENON ARM STYLE (SPECIFY-SEE ACCESSORIES CUTSHEET)
9.50"&10.25"DIA.BOLT CIRCLE EXAMPLE: (CHOOSE ONE)
AVPL-SSA4""-125-DM19-XXX-BLK-XXX AVPLSSA - 4" - 125
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Electric # APPLICATION FOR BUILDING PERMIT
Plumbing# 1175 Ellington Road Q
HVAC# Date: ff a0
Sprinkler# Estimated Cost $ Irr WI s�
FINAL APPROVALS Permit Fee $
Building COMPLETE RED BOXED AREAS Occupancy Fee
Engineering TYPE OR PRINT ONLY Eng. Insp. Fee $
Affidavit_ _
Appr.for Co. ► SIGN ON REVERSE SIDE A
Total Fee $
TO THE BUILDING DEPARTMENT, TOWN OF SOUTH WINDSOR, CT (Additional Cost) $
The undersigned hereby applies to do work according t t e ollo ing:
e
Applicant lV-12 LocationofWork J/ ;tV LotNo.
Applicant's Address Tel # C �?4 -��C 4-a
Town t Zip ���d Lic.# 'r015'9/
Owner �c�^ol S �• a ..�� /� Architect _
Owner's Address P tect's Address
eN— '9/Ib� ZiP�ft— Zip
Sq.Ft.New Area: 1 st Fl. 1 1 3rd FI. Total New Area A
Purpose of thi permit tw�av� n,�IN Grp�••�f f ��//y�, i^rto// �„�✓ �•z�G' /�
City Water❑ Well❑ Septic System D Sewer O
Ins: HO S Area Basement Garage
Approved by Use Group Construction Type
Revised 1108
I hereby agree to conform to all the requirements of the Laws of the State of Connecticut and the Ordinances of the Town of
South Windsor and to notify the Building Inspector of any alterati in the plans or speci ications of the Building for which this
permit is asked,and agree that this building is to be located t p per dist fro I street lines,side yard lines,and required
distances from all other zones and is located in which this it g and i e is wed.
Signed _ _ --
I hereby apply for a Certificate of cupancy for the work describ in this application for the permit.
Signed
DO NOT WRITE BELOW THIS LINE
INSPECTION COMMENTS
1900429 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER ELECTRICAL PERMIT
DATE: 10/16/2019
GIS ID:30301175 FEE: 5.98
MUNIS APPLICATION# 201902347 BUILDING DESCRIPTION:
APPLICANT, LOCATION
NAME: BLOOMFIELD ELECTRIC COMPANY ADDRESS: 1175 ELLINGTON ROAD
ADDRESS: 182 OAKWOOD DRIVE, OWNER: SOUTH WINDSOR TOWN OF 20
1175 ELLINGTON ROAD
GLASTONBURY,CT 06033
E
DESCRIPTION OF WORK: INSTALL NEW CONDUIT WIRING AND EXTERIOR PARKING LOT LIGHTS
SPECIAL CONDITIONS:
ALL WORK TO BE DONE IN ACCORDANCE WITH THE APPLICATION AND PLANS APPROVED BY THE BUILDING DEPARTMENT.
CONSTRUCTION TYPE:
OCCUPANCY GROUP: BUILDING OFFICIAL
10/16/2019 10:38 AM THE FEE ABOVE INCLUDES A$0.26 PER THOUSAND CT STATE EDUCATION SURCHARGE
1500468 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER BUILDING PERMIT
DATE: 08/17/2015
GIS ID: 30301175 FEE: 0.78
MUNIS APPLICATION# 201501096 BUILDING DESCRIPTION:
APPLICANT LOCATION
NAME: MANCHESTER AWNING&CANVAS ADDRESS: 1175 ELLINGTON ROAD
ADDRESS: 819 E.MIDDLE TPKE- OWNER: SOUTH WINDSOR TOWN OF 20
MANCHESTER,CT 06040-3724 1175 ELLINGTON ROAD
SOUTH WINDSOR,CT 06074
DESCRIPTION OF WORK: INSTALL AN AWNING OFF THE SIDE ENTRANCE.
SPECIAL CONDITIONS:
ALL WORK TO BE DONE IN ACCORDANCE WITH THE APPLICATION AND PLANS APPROVED BY THE BUILDING DEPARTMENT.
CONSTRUCTION TYPE:
OCCUPANCY GROUP: BUILDING OFFICIAL
8/17/2015 2:21 PM THE FEE ABOVE INCLUDES A$0.26 PER THOUSAND CT STATE EDUCATION SURCHARGE
1100078 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER ELECTRICAL PERMIT
DATE: 04/26/11
GIS ID:30301175 FEE: .26
MUNIS APPLICATION# 201100340 BUILDING DESCRIPTION:
APPLICANT LOCATION
NAME: PARADIS DON ADDRESS: 1175 ELLINGTON ROAD
ADDRESS: 11 PHEASANT WAY OWNER: SOUTH WINDSOR TOWN OF 20
SOUTH WINDSOR,CT 06074 1175 ELLINGTON ROAD
SOUTH WINDSOR,CT 06074
DESCRIPTION OF WORK: WIRE 240 VOLT 30 AMP CIRCUIT FOR NEW HOT WATER HEATER AT
FIRE HEADQUARTERS STATION 1.
SPECIAL CONDITIONS:
ALL WORK TO BE DONE IN ACCORDANCE WITH THE APPLICATION AND PLANS APPROVED BY THE BUILDING DEPARTMENT.
CONSTRUCTION TYPE:
OCCUPANCY GROUP: BUILDING OFFICIAL
4/26/201 l 2:39 PM THE FEE ABOVE INCLUDES A$0.26 PER THOUSAND CT STATE EDUCATION SURCHARGE