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HomeMy WebLinkAbout1209 SULLIVAN AVE APPLICATION FOR PERMANENT SIGN PERMIT Zoning Approval:) 1209 Sullivan Avenue Zoning Est. Cost: Final Inspections: No. 30462 Permit Fee: $3 O Building"" Appr4 d: Zoeit�"' EIS' Applicant/Business Name m 1T( V11�.Lt Po E,L OJ Address 22" �>u LL► vAa t'1 t1� Phone Location of Sign r Vc)►3T I S i A-U!D Zone TYPE of SIGN: ❑Wall or ElFree-standing N New or❑ Replacement Illuminated?❑Yes ' to Proposed Sign Size(square feet)�Sign Height_' No. of Existing signs on site Free-standing Wall Description of sign materials and lighting: )p z><O vQ' G�itA Mitou I� ATTACH ,c-rw (QQSe DIAGRAM OF SIGN INCLUDING I have read, understand and agree to abide by the South Windsor Zoring Regulations, Signs. DIMENSIONS Applicant 1 Date C-5 Property Owner �—� — Date / O A ark e ��5 , 3 X 6' (18 sq. ft.) carved on both sides, painted with premium sign enamels & genuine 23 kt gold leaf on letters & caps. 44R '-'. G 2 0�4 South Windsor BUILDING DEPARTMENT 9{a.:ftla a tt�at v is 1Yiae eN svwclq"tk oa are try. upics of the proposed tawfNing or alterations to M ratted at - I acj,: 1 an Avg .tr*a. - -g,they with amendments stated In application a-..: l�..d with plan and I agree to comply with all z Jnll -ilding and state laws and such orders as •hail oh i 1 aucd by the B'uilding Department during pend*r- tnis application and final Issuance of a bulldker ( 1—'ll( t t�_-1—� 'armit. �7J LAAl It 1�' 1OY--d Oj' his plan is approved subject to the coamflon that --C)Cr n `�"'�C w t• 1 N rs and ordinances regulating building shell be �©w ..lied with. a dltionally Approved T#eaa RAad With l�odtling Inspector n fileHi M "i��in'�L 1- _ LJ (�\ ..,ii ;,Jly ur LUNiNui Wivir''LIAINCL .!op,)sed buiidingis), use(s) andlor structures' is shown on this plan appear(s) to be ll. turmance with current South Wind- ;uiations. Variances and special exception:, ;y apply. ate O • X t s`` •� �„ t i� 10 "s [ ZZ3HD.LIY11 - let few SEPTIC \ *1209 j'ro I RICHARD J. ZIMMER �' \ r1�II JR N/F S=N � MITCHELL FUEL CO 1 ' / k S AN. M.N. �-- --� ` !r ST-A, 38-55 ` GRASS \ SEPTIC / SEP k ' S LEFT C / !— IC Jr cl-ap WELL I / j T`p Ua<• sign / #I19.9 0 PppL #II T —TAN. H, 1 S-m 40+15 BM 97 L `38 AT L 1 _ 14L A 2+� 15 IV/ CcaP cP" 3g S �'— 22o Lq7 eRgL cap 1005 r / _ 40 _ SEPTIC / l CcaP, r C4� wEcc O / l N/F Cc a,, ,� V�, qo. �94 I FAITH C. MARTIN '24 LATERALS T/c H O U s E STATIC)N LATERAL PIPE LENGTH 8 PI/C. STUi3 / 8COLLINS LA, /+ STa,. 40*75 ----- -_ - - 30+90 SLL%vNN AvE. 3L,F CPIIMNEYIo PVCi40�:Fl R0M No 2i ---- -- ---vc i + ULUVAN QVE I/1IYE- --y - 4O L.F �.@ 0.5� J .—�� _ 2 � I�271 SuLL►�AnI A - '3I la 5 - - t�"PYc.!�G[.F -`� FQo su"IvAN Avl; ,3460 SLLIVPJ AVE.� WYE NOT-E.' N/F : --- -- — �70 S VAN 1'wE, — 6 �y�48 V. s / 1224 Suu�VAN QvE t _ ULLI 2L.F �,�, rt rt- --, CONTROL- Bes6o 8 PVC STUB — — I Mq Y. I. ,2S LF, ON CG5 DATUM COLLINS JOHN P CALLAHAN ET. AL. / I212 Suu-%VAN Avc 37+Z5 SOLLIVAN 4VF'3�.F CHIMNE 6��P1/C'' p — - ,—I----- - - _Y �3o L.FI q L.F N.�0.51. � 120 7 SULL1vAN VE! t --' -- -------- -�� � - - --- - A .37 `1Q SULL\vAN Avc� 1�/yE 6-Py('138 Li 1 --- - — - - - --- { ,- -- / �194_S�L�LIA�I ,�vE 38t60PI!e. 331,F N AVE, t OFFICE SULL►VAN &6' 39M SULLIVAN A r �- IIl7 SuLu�AN QvEQQfB� SULLIvu AvE,! %l''3Q LF M/F-ALLAN a KATHERINE D. woo — — a WA soa�esis BOURNis A w PROM IM EXW • AOOITION sna►oE 102 1 4 l Aw t01 00 DRIVEWAY 50' BUILDING UNE 98 / i 04 100 SULLIVAN AVENUE CONN. ROWE 194 LEAD Septic System Design E MSTING CONTOUR S —— —— Deep Test Pert 'Kest Design - - pmWOSED CONTOURS a"" loam l"= Z5 minutes Use 1000 gallon septic tank , 6-54" sandy clay Loading- 1 gpd/sf ei`ea _. t at 36" 5 employees at 50 xis -PLAN WISED AOfltTi ION FOR Required Z50 sf M!TCHELL FUEL COMPANY Use 75 lf- S' vide WLLIVAN AVENUE SOUTH 90""K NO. REVISIONS OA'E E I": 4d DATE 10- 1-TB WIiSULTM ENGIKERS S aaauwo ROAD DUMB..*H. cntcxta E.W.L. 1 � ., �'e .' �, 1 d V 94 9Q I 98 N/F LAURA TOMLINSON —� 96 \00 2W 94 0. 73 LF•3'LEACHING_TLENCd N/F ALLAN Ik KATHERINE D. Ft 9— — �FL96.°-' 80 1000 GAL '�SOIL TESTS BOURN 00;sEPrir / 0' 1 ro' a, - ' 30'0 J PROPOSED EXIXT. ' ADDITION 6pGAGE - 102' FF 105.8 .,FF 105.8 1p4 12-2 106 II � DRIVEWAY � j e 120 -� / /� -ry 406199 50' BUILDING L 98 —� / 104 JOO isl anc� I 4231 Ius. SULLIVAN AVENUE CONN. ROUTE 194 LEGEND Septic System Design EXISTING CONTOURS -=— Deep Test Perc Test Design ' PROPOSED CONTOURS—J 0-6" loam 1"= 25 minutes Use 1000 gallon septic tank 6-54" sandy clay Loading- 1 gpd/sf -leacupg area at 36" 5 employees at 50 gpren 250 gpd:_o_ts Required 250 sfUse 75 lf- 3' wide t j SULLIV 71 APJ 'Al H ~ -O-Wt-2, O-P SOUM, Vr;fldj�Ot o � 1540 SULLIVAN AVENUE - SOUTH WINDSOR. CONN. 06074 ~osoR-Co� AREA CODE 203/644-2511 May 13, 1985 CERTIFIED MAIL Mitchell Fuel Co., Inc. 1209 Sullivan Avenue South Windsor, CT 06074 Attention: John J.-Mitchell, Jr., Vice President Dear Mr. Mitchell: The application of Mitchell Fuel Company, Inc. to the South Windsor Zoning Board of Appeals requesting a variance to Section 4.3.6 of the Zoning Regulations has been granted. The Board voted to allow one free-standing sign not to exceed 24 square feet to be located at the south edge of the driveway, six feet from the road, as shown on the map submitted with the application. In granting this variance the Board noted that it was difficult to see the business from the street, and the additional sign would help. The Board indicated that the sign should include the name of the business. This action is effective May 24, 1985 and upon your filing the enclosed form in the Town Clerk's Office. Very truly yours, Thomas Murrin, Chaim a i Zoning Board of Appeals TM/src encl. ECEIVE • - A (BAR 21 2012 Not WdnVNIRMund Stord U� CPPU USE ONLY App M Please complete this entire form,where applicable, in Doc M accordance with the instructions(DEP-UST-INST-001)to ensure the proper handling of your notification. Print or type Check M unless otherwise noted. Submit one notification form per site. Part I: Notification and Fee Type Check the appropriate box(es)identifying the notification type. 1. LOCATION of UST(s) Name of site: 1!_l Street Address or Location,Descri ption:City/Towni W\ State: Zip Code: 2. Site ID Number, if known: `y- 3. This notification is for(check all that apply): Fee *Number of Tanks Total Fee= (a) (b) (a x b) [� An annual $100.00/per tank 900�-- ❑ fee exempt tanks $0 ❑ adding new UST system $100.00/per tank ❑ fee exempt tanks $0 ❑ adding an orphan UST system newt $100.00/ er tank Y (newly p discovered) ❑ fee exempt tanks $0 ❑ update/correction to owner/site info $0 ❑ update/correction to UST system info $0 ❑ Permanent Closure of an UST system $0 •Compartmentalized tanks are counted as one tank. "Total Fee Z�! 'For municipalities,the 50%discount applies. The notification will not be processed without the fee.The fee shall be non-refundable and shall be paid by check or money order to the Department of Environmental Protection. DEP-UST-NOT-001 1 of 9 Rev.02/18/11 Part II: Owner/Operator Information If identifying an entity registered with the Secretary of the State, fill In the name exactly as it is shown on such registration. 1. Owner/Operator Name: E 6h v\', Mailing Address: P•O•"RR,c �t(p3 City/Town:SDLAZ VV W t A9L5C (-/ State: VT Zip CodeO(p ���-- Business Phone: %04oL4-2.,<)GA ext.. Fax: '::�(QO-<o $ Contact Person:SCE At-CxS 4'r\1Xv2-, Phone: ext. Business Type(check one): Er private ❑ federal gov't ❑ state gov't ❑ local gov't ❑ tribal' Notification or fee is NOT required for UST systems located on tribal lands. ❑ Check if any co-owners. If so,attach additional sheet(s)with the required information as requested above. Owner's interest in property or facility at which the proposed activity is to be located: (check all that apply) ❑ storage tank owner ❑ billing contact 19 property owner ❑ storage tank operator ❑ facility owner/operator ❑ other(specify): 2. List primary contact person in charge of tanks,if different than the owner. Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext. Fax: Contact Person: Title: Email: 3. List storage tank operator,if different than the owner. Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext. Fax: Contact Person: Title: Email: 4. List billing contact,if different than the owner. Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext. Fax: Contact Person: Title: Email: DEP-UST-NOT-001 2 of 9 Rev.02/18/11 Part II: Owner/Operator Information (continued) 5. Financial Responsibility Other than through state funds,check the applicable box(es)by the following mechanisms to identify how you have met financial responsibilities requirements. (check all that apply): ❑ Self Insurance ❑ Guarantee ❑ Bond Rating Test E4 Commercial Insurance ❑ Surety Bond ❑ Trust Fund ❑ Risk Retention Group ❑ Letter of Credit ❑ Local Government ❑ Other Method(specify): Financial Test Part III: Site Information TYPE OF SITE(check all that apply): ❑ Air Taxi(Airline) ❑ Federal Non-Military Private ❑ Aircraft Owner ❑ Gas Station ❑ Railroad ❑ Auto Dealership ❑ Industrial ❑ Residential Commercial ❑ Local Government ❑ School �( Contractor ❑ Marina ❑ State ❑ Convenience Store ❑ Municipal ❑ State Government ❑ Farm ❑ Other ❑ Trucking/Transport ❑ Federal R1 Petroleum Distributor ❑ Utilities ❑ Federal-Military DEP-UST-NOT-001 3 of 9 Rev.02/18/11 Part IV: Underground Storage Tank Information Complete for all tanks and piping at the subject location. If you have more than 5 tanks in one location, reproduce this Part and complete for additional tanks. Tank Identification Number Tank No.: Tan No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Tank Construction 1. Status of Tank Currently in Use Qr Qr ❑ ❑ ❑ Temporarily Closed ❑ ❑ ❑ ❑ ❑ Date Temporarily Closed Permanently Closed ❑ ❑ ❑ ❑ ❑ 2. Emergency Generator Use Only ❑ ❑ ❑ ❑ ❑ 3. Date of Installation of Tank(month/year) 4. Life Expictancy of Tank(years) 30 30 5. Estimated Total Capacity of Tank(gallons) 6. Substance Currently Stored in Tank(or last stored in the case of closed tanks) Gasoline ❑ fz� ❑ ❑ ❑ Diesel 0 ❑ ❑ ❑ ❑ Kerosene ❑ ❑ ❑ ❑ ❑ Heating Oil(on-site consumption) ❑ ❑ ❑ ❑ ❑ Heating Oil(for resale) ❑ ❑ ❑ ❑ ❑ Used Oil ❑ ❑ ❑ ❑ ❑ Gasohol ❑ ❑ ❑ ❑ ❑ Biofuel ❑ Cl ❑ ❑ ❑ If Other,please specify here Hazardous Substance ❑ ❑ ❑ ❑ ❑ CERCLA name and/or CAS Number Mixture of Substances ❑ ❑ ❑ ❑ ❑ Please specify substances here 7. Material of Construction of Tank Asphalt Coated or Bare Steel ❑ ❑ ❑ ❑ ❑ Coated and Cathodicaliy Protected Steel(STI-P3) ©' Ur ❑ ❑ Cl Composite(Steel clad with Fiberglass) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Plastic Jacket) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Urethane) ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ ❑ ❑ ❑ ❑ Other(e.g.,concrete,etc.)(please specify) DEP-UST-NOT-001 4 of 9 Rev.02/18/11 Part IV: Underground Storage Tank Information (continued) Tank Identification Number Tank No.: Tank o.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ �❑ ❑ Cl ❑ 7. Material of Construction of Tank(continued) Lined Interior ❑ ❑ ❑ ❑ ❑ Excavation Liner ❑ ❑ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑ ❑ Tank Manufacturer Check box if tank has ever been repaired ❑ ❑ ❑ ❑ ❑ 8. Primary Release Detection-Tank Annual Precision Tightness Testing ❑ ❑ ❑ ❑ ❑ t Tank Tightness Test with Inventory Control ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ ATG Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ ATG-CSLD—Continuous with Inventory �• ❑ El ❑ Reconciliation/Control or ATG-Static with Inventory Reconciliation/Control ❑ ❑ ❑ ❑ ❑ Monthly Groundwater/Vapor Monitoring ❑ ❑ ❑ ❑ ❑ Manual Tank Gauging ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ Cl ❑ ❑ ❑ Automatic Tank Gauging 12' iz ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ Cl ❑ ❑ If Other Method,please specify here Piping Construction 9. Piping Installation Date 10. Piping Material Bare Steel ❑ ❑ ❑ ❑ ❑ Galvanized Steel ❑ ❑ ❑ ❑ ❑ Epoxy Coated Steel �' 0' ❑ ❑ ❑ Flexible Plastic ❑ ❑ ❑ ❑ ❑ No Piping associated with Tank or Above Ground Only ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ ❑ ❑ ❑ ❑ Semi-Rigid Plastic ❑ ❑ ❑ ❑ ❑ Copper ❑ ❑ ❑ ❑ ❑ Containment Sumps at Dispensers ❑ ❑ ❑ ❑ ❑ Containment Sumps at Tanks ❑ ❑ ❑ ❑ ❑ Metallic Fitting Isolated from Soil and Water ❑ ❑ ❑ ❑ ❑ Metallic Fitting Cathodically Protected ❑ ❑ DEP-UST-NOT-001 5 of 9 Rev.02/18/11 Part IV: Underground Storage Tank Information (continued) Tank Identification Number Tank INO.: Tank Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ 10. Piping Material(continued) Cathodically Protected lirJ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑ ❑ Unknown ❑ ❑ ❑ ❑ ❑ If Other,please specify here 11. Piping Type(must check one for each tank) Pressure ❑ ❑ ❑ ❑ ❑ 'U.S.'Suction(valve at tank) ❑ t ❑ ❑ ❑ ❑ No Underground Product Piping or Gravity Feed Only ❑ ❑ ❑ ❑ ❑ "Safe'Suction(no valve at tank) f3 V ❑ ❑ ❑ Check box if piping has ever been repaired ❑ ❑ ❑ ❑ ❑ 12. Primary Release Detection-Piping Annual Precision Line Tightness Testing ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ GroundwaterNapor Monitoring ❑ ❑ ❑ ❑ ❑ PLLD—Annual.Igph Leak Test ❑ ❑ ❑ ❑ ❑ PLLD—Monthly Elec.0.2gph Leak Testing ❑ ❑ ❑ ❑ ❑ Precision Line Tightness Testing Every 3 years 9 QJ ❑ ❑ ❑ Statistical Inventory Reconciliation(SIR) ❑ ❑ ❑ ❑ ❑ Automatic Line Leak Detectors ❑ ❑ ❑ ❑ ❑ Electronic Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑ Mechanical Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ Cl If Other Method,please specify here 13. Spill and Overfill Protection Overfill Device Installed Audible Alarm ❑ ❑ ❑ Ball Float Device ❑ ❑ ❑ ❑ ❑ Flapper Device ❑ ❑ ❑ ❑ ❑ None ❑ ❑ ❑ ❑ ❑ Other(please specify) Spill Device Installed ❑ ❑ ❑ ❑ ❑ DEP-UST-NOT-001 6 of 9 Rev.02/18/11 Part V: Permanent Tank Closure Tank Identification Number Tank No.: Tank Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ �❑ ❑ Cl ❑ 1. General Information of Closed Tank Date of Installation(month/year) Estimated Total Capacity(gallonslyear) Estimated date tank closed(month/day/year) (check one per tank): Tank was removed from ground ❑ ❑ ❑ ❑ ❑ Tank was closed in ground ❑ ❑ ❑ ❑ ❑ Tank filled with inert material ❑ ❑ ❑ ❑ ❑ Describe the inert fill material here 2. Estimated date the UST was last used for storing regulated substances(month/day/year) 3. Site Assessment Required Site Assessment Completed ❑ ❑ ❑ ❑ Cl (If Yes,provide consultant/contractor information below) Consultant/Contractor Name(s) Consultant/Contractor Addresses(s) Consultant/Contractor Phone(s) Soil Samples Collected and Analyzed for one or more of El ❑ ❑ El ❑ the following: VOCs,SVOCs,Metals,ETPH Groundwater Encountered During Assessment ❑ ❑ ❑ ❑ ❑ Groundwater Samples Collected and Analyzed for one or ❑ ❑ ❑ ❑ Elmore of the following: VOCs,SVOCs,Metals,ETPH *Soil Samples had Constituents of Concern above the following RSKCdteda: 'GA PMC ❑ ❑ ❑ ❑ ❑ GB PMC ❑ ❑ ❑ ❑ ❑ Res DEC ❑ ❑ ❑ ❑ ❑ I/C DEC ❑ ❑ ❑ ❑ ❑ If any boxes were checked,include a table summarizing the data and highlighting the exceedances (See R.C.SA. Sections 22a-133k-1 through 3 for definitions). *Groundwater Samples had Constituents of Concern above the following RSR Criteria: GWPC ❑ ❑ ❑ ❑ ❑ SWPC ❑ ❑ ❑ ❑ ❑ Res GWVC ❑ ❑ ❑ ❑ ❑ I/C GWVC ❑ ❑ ❑ ❑ ❑ If any boxes were checked,include a table summarizing the data and highlighting the exceedances (See R.C.SA. Sections 22a-133k-1 through 3 for definitions). DEP-UST-NOT-001 7 of 9 Rev.02/18/11 Part V: Permanent Tank Closure (continued) Tank Identification Number Tani No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Remedial Actions Recommended by Environmental Consultant/Contractor ❑ ❑ ❑ ❑ ❑ If box is checked,a closure report must be submitted to the LUST Coordination Program for evaluation. Remedial Actions Completed If box is checked,a closure report must be submitted to the ❑ ❑ ❑ ❑ ❑ LUST Coordination Program for evaluation. Part VI: Certification of Installation Complete within 30 days of installing an UST or adding an UST system to an existing notification. If you have more than 5 tanks in one location, reproduce this part and complete for additional tanks. Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a Compartmentalized Tank ❑ ❑ ❑ ❑ ❑ Installer of tank and piping must check all that apply ❑ ❑ ❑ ❑ ❑ Installer certified by tank and piping manufacturers ❑ ❑ ❑ ❑ ❑ Installation inspected by a registered engineer ❑ ❑ ❑ ❑ ❑ Installation inspected and approved by implementing ❑ ❑ ❑ ❑ ❑ agency Manufacturer's installation checklists have been ❑ ❑ ❑ ❑ ❑ completed If Other Method,please specify here Provide signature of UST Installer to certify proper installation of subject UST System. Signature of UST Installer Date Name of UST Installer (print or type) Title Company Name DEP-UST-NOT-001 8 of 9 Rev.02/18/11 Part VII: Owner/Operator Certification The owner/operator and the individual(s)responsible for actually preparing the notification must sign this part.A notification will be considered incomplete unless all required signatures are provided. "I have personally examined and am familiar with the information submitted in this document and all attachments thereto,and I certify that based on reasonable investigation, including my inquiry of the individuals responsible for obtaining the information,the submitted information is true,accurate and complete to the best of my knowledge and belief. I understand that a false statement in the submitted information may be punishable as a criminal offense, in accordance with section 22a-6 of the General Statutes, pursuant to section 53a-157b of the General Statutes, and in accordance with any other applicable statute. I certify that this underground storage tank notification is on complete and accurate forms as prescribed by the commissioner without alteration of the text." /1-V k, dw -L3(iH 2- Sign ture-of Owr)600perahor ' Date Name of Owner/Operator(print or type) Title(if applicable) Signature of Preparer(if different than above) Date Name of Preparer(print or type) Title(if applicable) ❑ Check here if additional signatures are required. If so, please reproduce this sheet and attach signed copies to this sheet. Note: Please submit a completed Underground Storage Tank Notification and all Supporting Documents to: CENTRAL PERMIT PROCESSING UNIT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM STREET HARTFORD, CT 06106-5127 A copy of this completed Notification Form must also be forwarded to the local fire marshal. If you have any questions, please contact the UST Program at 860-424-3374 or by a-mail (DEP.USTFeeCcDct.gov) DEP-UST-NOT-001 9 of 9 Rev.02/18/11 Connecticut Department of Energy & Environmental Protection Bureau of Materials Management & Compliance Assurance Emergency Response & Spill Prevention Division Notification for Underground CPPU USE ONLY Storage Tanks App#: Please complete this form,in accordance with the instructions Doc#: (DEEP-UST-INST-001)to ensure the proper handling of your notification. Print or type unless otherwise noted. Check#: Submit one notification form per site. Part I: Notification and Fee Type Program: UST Check the appropriate box(es)identifying the notification type. 1. LOCATION of UST(s) Name Of site: MITCHELL FUEL CO.,INC Street Address or Location Description: PO BOX 1163 City/Town: SOUTH WINDSOR State: CT Zip Code: 06074-7163 2. UST Site ID Number: 132-2314 No.of Fee *No.of 3. This notification is for: exempt Tanks Total choose i,ii,iiior iv Fee excluding(b) Fee= (a) (b) (c) (a x c) ❑ i) first time site notification[new] $100.00/ (Complete entire application) tank [#1032[ ❑ ii)annual notification[renewal]with NO $100.00/ modifications tank (Complete Parts 1 and VII only) [#1032[ 0 iii)annual notification[renewal] with modifications,(specify modifications under $100.00/ iv below) tank (Complete Parts I and VII and [#1032[ modifications only) 0 1 2 $200 ❑✓ iv) a modification to an existing notification;check any of the following to specify. (Complete Parts I and VII and modifications only) ❑ adding new UST system(Part IV) $100.00/ tank [#1032[ 0 0 $0 DEEP-UST-NOT-001 1 of 12 Rev.12/18/12 Part 1: Notification and Fee Type (continued) No.of Fee *No.of exempt Tanks Total 3. (modifications continued) Fee tanks($O) excluding(b) Fee= (a) (b) (c) (a x c) ❑ adding an orphan UST system(newly $100.00/ discovered)(Part IV) tank [#10321 0 0 $0 ❑ update/correction to Part 11: $0 owner/operator info/financial responsibility ❑ transfer of ownership(Part 11) $0 ❑ update/correction to Part III:record info $0 ❑ update/correction to Part IV:UST system $0 info ❑ Permanent Closure of an UST system $0 (Part V) I r 0 $0 *Compartmentalized tanks are counted as one tank. *Manifolded or interconnected tanks count as separate tanks *Total Fee: $200 *For municipalities,the 50%discount applies.The notification will not be processed without the fee.The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection. Part II: Owner/Operator Information *If an Owner/Operator is a corporation,limited liability company,limited partnership,limited liability partnership,or a statutory trust,it must be registered with the Secretary of State.If applicable,the applicant's name shall be stated exactly as it is registered with the Secretary of State.Please note,for those entities registered with the Secretary of State,the registered name will be the name used by DEEP. This information can be accessed at the Secretary of State's database (CONCORD). (www.concord-sots.ct.gov/CONCORD/index.jsp) If an Owner/Operator is an individual,provide the legal name(include suffix)in the following format:First Name;Middle Initial,Last Name;Suffix(Jr,Sr.,It,III,etc.). 1. UST Owner Name: MITCHELL FUEL CO.,INC. This affiliate is the registrant(check if true): ❑✓ Mailing Address: 1209 SULLIVAN AVE City/Town: SOUTH WINDSOR State: CT Zip Code: 06074 Business Phone: (860)644-2561 ext.: Contact Person: JOHN MITCHELL,JR Phone: ext. *E-mail: JOHN@MITCHELLFUEL.COM *By providing this e-mail address you are agreeing to receive official correspondence from the department,at this electronic address,concerning the subject application.Please remember to check your security settings to be sure you can receive a-mails from"ct.gov"addresses.Also,please notify the department if your e-mail address changes a) Business Type(check one): ❑ individual ❑ federal agency ❑ state agency ❑ municipality ❑ **tribal 0 *business entity(*If a business entity complete i through ii): DEEP-UST-NOT-001 2 of 12 Rev.12/18/12 Part II: Owner/Operator Information i) provide Secretary of the State business ID#: 0072668 This information can be accessed at the Secretary of State's database(CONCORD).(www.concord-sots.ct.gov/CONCORD/index.jsp) ii) ❑ Check here if your business is NOT registered with the Secretary of State's office. **Notification or fee is NOT required for UST systems located on tribal lands. 2. UST Operator Name: MITCHELL FUEL CO.,INC. This affiliate is the registrant(check if true): ❑ Mailing Address: 1209 SULLIVAN AVE City/Town: SOUTH WINDSOR State: CT Zip Code: 06074 Business Phone: (860)644-2561 ext.. Contact Person: JOHN MITCHELL,JR Phone: (860)644-2561 ext. *E-mail: a) Business Type(check one): ❑ individual ❑ federal agency ❑ state agency ❑ municipality ❑ **tribal .r❑ *business entity(*If a business entity complete i through ii): i) provide Secretary of the State business ID#: 0072668 This information can be accessed at the Secretary of State's database(CONCORD).(www.concord-sots.ct.gov/CONCORD/index.jsp) ii) ❑ Check here if your business is NOTregistered with the Secretary of State's office. **Notification or fee is NOT required for UST systems located on tribal lands. ❑Check if any co-owners/operators.If so,attach additional sheet(s)with the required information as requested above. 3. Billing contact Name: MITCHELL FUEL CO.,INC. Mailing Address: 1209 SULLIVAN AVE City/Town: SOUTH WINDSOR State: CT Zip Code: 06074 Business Phone: (860)644-2561 ext.: Contact Person: JOHN MITCHELL,JR Phone: ext. E-mail: JOHN®MITCHELLFUEL.COM 4. Primary contact, if different than UST owner Name: MITCHELL FUEL CO.,INC. Mailing Address: 1209 SULLIVAN AVE City/Town: SOUTH WINDSOR State: CT Zip Code: 06074 Business Phone: (860)644-2561 ext,: Contact Person: JOHN MITCHELL,JR Phone: ext. *E-mail: JOHN@MITCHELLFUEL.COM *By providing this e-mail address you are agreeing to receive official correspondence from the department,at this electronic address,concerning the subject application.Please remember to check your security settings to be sure you can receive a-mails from"ct.gov"addresses.Also,please notify the department if your e-mail address changes. DEEP-UST-NOT-001 3 of 12 Rev.12/18/12 Part 11: Owner/Operator Information (continued) 5. Property Owner, if different than UST owner Name: MITCHELL FUEL CO.,INC. Mailing Address: 1209 SULLIVAN AVE City/Town:SOUTH WINDSOR State: CT Zip Code: 06074 Business Phone: (860)644-2561 ext.: Contact Person: JOHN MITCHELL,JR Phone: ext. E-mail: JOHN®MITCHELLFUEL.COM 6. Class A Operator: must be the individual who was trained. Name: Joe Paterak Mailing Address: 189 Atwater St City/Town: Plantsville State: CT Zip Code: 06479 Business Phone: (860)276-1201 ext.: E-mail: jpaterak®aaronenvironmental.com Company Name,if applicable: Aaron Environmental,I.I.C. Approved Training Course: PASS Connecticut Class A/B Operator Training Training Date: 8 Aug 2014 ❑✓ initial or biennial training OR ❑ retraining ordered for non-compliance Certification Expiration Date: 7 Aug 2016 Class A Operator's Signature: josky1236 Signed on:5/19/2016 12:45:35 7. Class B Operator: must be the individual who was trained. Name: Joe Paterak Mailing Address: 189 Atwater St City/Town: Plantsville State: CT Zip Code: 06479 Business Phone: (860)276-1201 ext.. E-mail: jpaterak®aaronenvironmental.com Company Name,if applicable: Aaron Environmental,LLC. Approved Training Course:PASS Connecticut Class A/B Operator Training Training Date: 8 Aug 2014 ❑✓ initial or biennial training OR ❑ retraining ordered for non-compliance Certification Expiration Date: 7 Aug 2016 Class B Operator's Signature: josky1236 Signed on:5/19/2016 12:45:35 DEEP-UST-NOT-001 4 of 12 Rev.12/18/12 Part II: Owner/Operator Information (continued) S. Financial Mechanism(s):Complete the table below identifying the financial assurance mechanism(s)used to demonstrate financial responsibility as specified in the Federal Register. Use the list of surety types below. If an 'other method'is chosen, please specify the method in the table. A. Self Insurance E. Guarantee I. Trust Fund B. Commercial Insurance F. Surety Bond J. *State Fund C. Risk Retention Group G. Letter of Credit K. Other Method (specify in D. Local Government H. Bond Rating Test table below) Financial Test *Pursuant to section 262 of Public Act 12-1 of the June 12`'Special Session,the state fund(UST Petroleum Clean-Up Program)will cease to serve as a financial responsibility mechanism on: October 1, 2012,for those who own or operate USTs on more than five separate sites;and October 1, 2013 for municipalities and for those who own or operate USTs on five or less separate sites. Surety Type Policy (insert letter Amount Coverage Coverage Name Of Insurer Number from list above Of Start End Coverage Date Date or specify) MITCHELL FUEL CO.,INC. B.Commercial Insurance BTA999069502 51,000,000 1 Oct 2015 1 Oct 2016 Owners/Operators shall complete the attached"Certification of Financial Responsibility Form"and maintain such completed form at the facility where the storage tank system(s)are located.THIS FORM DOES NOT NEED TO BE SUBMITTED but must be updated to reflect any changes. Part III: Record Information Off-Site Storage of Records at a Centralized Location Does the owner/operator of more than 10 facilities with UST systems request to store certain records at a centralized location? ❑ Yes (Leave unchecked if'No') If yes, provide the central location address below. Address: City/Town: State: Zip Code: - Such records must be immediately available for inspection by the commissioner or the commissioner' s designee at any such central location. Please refer to section 22a-449 q CGS; for storage of underground storage tank system records that may be kept at a centralized location or that must be kept on site. DEEP-UST-NOT-001 5 of 12 Rev.12/18/12 Part IV: Underground Storage Tank Information Complete for all tanks and piping at the subject location. Begin by labeling tanks(including compartments, if applicable). Label tanks as required by the instructions. If you have more than 5 tanks in one location, reproduce this section and complete for additional tanks.You must read the instructions(DEEP-UST-INST-001) in order to properly complete this Part. Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number(see instructions) A1R1 A2 Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ Complete items 1 through 5 for the entire tank-you do not have to complete the columns labeled for compartments. 1. Status of Tank Currently in Use ✓❑ ❑✓ ❑ ❑ ❑ Temporarily Closed ❑ ❑ ❑ ❑ ❑ Date Temporarily Closed Permanently Closed(check here and skip to Part 10 ❑ ❑ ❑ ❑ ❑ 2. Date of Installation of Tank(month/year) 08/01/1998 08/01/1998 3. Life Expectancy of Tank(years) 30 30 4. Material of Construction-Tank-check one per tank Asphalt Coated or Bare Steel ❑ ❑ ❑ ❑ ❑ Coated and Cathodically Protected Steel(STI-123) ❑ ❑✓ ❑ ❑ ❑ Composite(Steel clad with Fiberglass) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Plastic Jacket) O ❑ ❑ O O Composite (Steel with Urethane) ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ ❑ ❑ ❑ ❑ Other(e.g., concrete, etc.) (please specify) 5. Construction Type-Tank- check all that apply Lined Interior with Epoxy Coating ❑ ❑ ❑ ❑ ❑ Excavation Liner ❑ ❑ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑ ❑ Single Walled 0 ❑✓ ❑ ❑ ❑ Tank Manufacturer other Other Check box if tank has ever been repaired 1 ❑ ❑ ❑ ❑ ❑ Complete the following for each compartment or tank. 6. Emergency Generator Use Only ❑ ❑ ❑ ❑ ❑ 7. Estimated Total Capacity(gallons) 2000 1000 Farm Use ❑ ❑ [] ❑ ❑ DEEP-UST-NOT-001 6 of 12 Rev. 12/18/12 Part IV: Underground Storage Tank Information (continued) Tank Identification Number (see instructions) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: A1R1 A2 Part of a compartmentalized tank ❑ ❑ ❑ O O Part of a manifolded or interconnected tank j ❑ j ❑ j ❑ j ❑ j ❑ 8. Substance Currently Stored(or last stored in the case of closed compartmentsftanks) check one per compartment/tank Gasoline ❑ ❑✓ ❑ ❑ ❑ Diesel 0 ❑ ❑ ❑ ❑ Kerosene (for resale) O O ❑ O O Kerosene (on-site consumption) ❑ ❑ ❑ ❑ ❑ Heating Oil(on-site consumption) ❑ ❑ ❑ ❑ ❑ Heating Oil(for resale) ❑ ❑ ❑ ❑ ❑ Used Oil ❑ ❑ ❑ ❑ ❑ Biodiesel ❑ ❑ ❑ ❑ ❑ E-85 ❑ ❑ ❑ ❑ ❑ E-15 ❑ ❑ ❑ ❑ ❑ If Other, please specify here Hazardous Substance ❑ ❑ ❑ ❑ ❑ CERCLA name CAS Number 9. Primary Release Detection-check one per compartment/tank Annual Precision Tightness Testing ❑ ❑ ❑ ❑ ❑ Tank Tightness Test with Inventory Control ❑ ❑ ❑ ❑ ❑ Continuous(Electronic) Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ ATG-CSLD—Continuous with Inventory ❑ ❑ ❑ ❑ ❑ Reconciliation/Control ATG-Static with Inventory Reconciliation/Control ❑✓ ❑✓ ❑ ❑ ❑ Monthly Groundwater/Vapor Monitoring ❑ ❑ ❑ ❑ ❑ Manual Tank Gauging ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method, please specify here DEEP-UST-NOT-001 7 of 12 Rev.12118/12 Part IV: Underground Storage Tank Information (continued) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number A1R1 A2 Part of a compartmentalized tank D ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ Piping Construction 10.Piping Installation Date 08/01/1998 08/01/1998 11. Piping Material - check one per compartment tank Bare Steel ❑ ❑ ❑ ❑ ❑ Galvanized Steel ❑ ❑ ❑ ❑ D Epoxy Coated Steel Q Q ❑ ❑ ❑ Flexible Plastic ❑ ❑ ❑ ❑ ❑ No Piping associated with Tank or Above Ground Only ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ ❑ ❑ ❑ ❑ Semi-Rigid Plastic ❑ ❑ ❑ ❑ ❑ Copper ❑ ❑ ❑ ❑ ❑ Other ❑ ❑ ❑ ❑ ❑ 12.Piping-Secondary Containment- check all d at apply Containment Sumps at Dispensers ❑ ❑ ❑ ❑ ❑ Containment Sumps at Tanks ❑ D ❑ ❑ ❑ 13. Pipe Fitting- check one per compartmenNtank Metallic Fitting Isolated from Soil and Water ❑ ❑ ❑ ❑ ❑ Metallic Fitting Cathodically Protected Q ❑✓ ❑ ❑ ❑ 14.Construction Type-Piping- check all that app Cathodically Protected ✓❑ Q ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑ ❑ Metallic Piping Isolated form Soil and Water Q Q ❑ ❑ ❑ Single Walled Q Q D ❑ ❑ Unknown ❑ ❑ ❑ ❑ ❑ 15.Piping Type- check one per compartment/tank Pressure ❑ ❑ ❑ ❑ ❑ 'U.S."Suction(valve at tank) ❑ ❑ ❑ ❑ ❑ Gravity Feed Only ❑ ❑ ❑ ❑ ❑ 'Safe-Suction(no valve at tank) ❑✓ Q ❑ D ❑ If Other,please specify here Check box if piping has ever been repaired ❑ ❑ ❑ ❑ ❑ DEEP-UST-NOT-001 8 of 12 Rev.12/18/12 Part IV: Underground Storage Tank Information (continued) Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number A1R1 A2 Part of a compartmentalized tank Q ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank r-11 ❑ ❑ ❑ ❑ 16.Primary Release Detection-Piping- check one per compartment/tank Annual Precision Line Tightness Testing Q Q ❑ Q Q Precision Line Tightness Testing Every 3 years ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Groundwater/Vapor Monitoring ❑ ❑ ❑ ❑ ❑ PLLD-Annual Agph Leak Test ❑ ❑ ❑ ❑ ❑ PLLD-Monthly Elec.0.2gph Leak Testing ❑ ❑ Q ❑ ❑ No release detection required(see instructions) d❑ 21 Q ❑ ❑ If Other Method,please specify here 17.If piping type is pressure- check one per compartment/tank Electronic Auto Line Leak Detectors I ❑ ❑ ❑ [) ❑ Mechanical Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑ 18.Spill and Overfill Protection- check all that apply Audible Alarm 0 ❑✓ ❑ ❑ ❑ Ball Float Device ❑ ❑ ❑ ❑ ❑ Flapper Device ❑ ❑ ❑ ❑ ❑ None ❑ ❑ ❑ ❑ ❑ Spill Prevention Device Installed Q✓ ❑✓ ❑ ❑ ❑ Part V: Permanent Tank Closure Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank 7 ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank Q ❑ ❑ ❑ ❑ 1. General Information of Closed Tank Date of Installation(month/year) Estimated Total Capacity(gallons) Estimated date tank closed(month/day/year) (check one per tank): Tank was removed from ground ❑ ❑ ❑ ❑ ❑ Tank was closed in ground Q ❑ ❑ ❑ ❑ Tank filled with inert material ❑ ❑ ❑ ❑ ❑ Describe the inert fill material here DEEP-UST-NOT-001 9 of 12 Rev.12118I12 Part V: Permanent Tank Closure (continued) Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Part of a manifolded or interconnected tank ❑ ❑ ❑ ❑ ❑ 2. Estimated date the UST was last used for storing regulated substances(month/day/year) 3. Site Assessment Required Site Assessment Completed ❑ ❑ ❑ ❑ ❑ (It Yes,provide Consultant/Contractor information below) Consultant/Contractor Name(s) Consultant/Contractor Addiesses(s) Consultant/Contractor Phone(s) Soil Samples Collected and Analyzed for one or more of ❑ ❑ ❑ ❑ ❑ the following. VOCs,SVOCs,Metals,ETPH Groundwater Encountered During Assessment ❑ ❑ ❑ ❑ ❑ Groundwater Samples Collected and Analyzed for one or ❑ El ❑ ❑ ❑ more of the following. VOCs.SVOCs,Metals,ETPH 'Soil Samples had constituents of concern above the following RSR Criteria: - check all that apply CAPMC ❑ ❑ ❑ ❑ ❑ GB PMC ❑ ❑ ❑ ❑ ❑ Res DEC Cl ❑ ❑ ❑ ❑ IIC DEC ❑ ❑ ❑ ❑ ❑ •It any boxes were checked above,include a table summarizing the data and highlighting the exreedances (See R.C.S.A.Sections 22a- 133k-1 through 3 for definitions), •Groundwater Samples had Constituents of Concern above the following RSR Criteria: - check all that apply GWPC ❑ ❑ ❑ ❑ ❑ SWPC ❑ ❑ ❑ ❑ ❑ Res GWVC ❑ ❑ ❑ ❑ ❑ I/C GWVC ❑ ❑ ❑ ❑ ❑ If any boxes were checked above,include a table summarizing the data and highlighting the exceedances (See R.C.S.A.Sections 22a- 133k-1 through 3 for definitions). Remedial Actions Recommended by Environmental Consultant/Cont"Or ❑ ❑ ❑ ❑ ❑ If box is checked.a closure report must be submitted to the LUST Coordination Program for evaluation. Remedial Actions Completed If box is checked,a closure report must be submitted to the ❑ ❑ ❑ ❑ ❑ LUST Coordination Program for evaluation. DEEP-UST-NOT-001 10 of 12 Rev.12/18112 Part VI: Certification of Installation Complete within 30 days of installing an UST or adding an UST system to an existing notification. If you have more than 5 tanks in one location, reproduce this part and complete for additional tanks. Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Tank Identification Number Part of a Compartmentalized Tank ❑ ❑ ❑ ❑ ❑ Installer of tank and piping must check all that apply Installer certified by tank and piping manufacturers ❑ ❑ ❑ ❑ ❑ Installation inspected by a registered engineer ❑ ❑ ❑ ❑ ❑ Installation inspected and approved by implementing ❑ ❑ ❑ ❑ ❑ agency Manufacturer's installation checklists have been ❑ ❑ ❑ ❑ ❑ completed If Other Method,please specify here Provide signature of UST Installer to certify proper installation of subject UST System. Company Name: License Type: Company Address: City/Town: State: Zip Code: Business Phone: ext.. Name of UST Installer(print or type): Title: E-mail: Phone: ext.: Signature and Date of UST Installer: DEEP-UST-NOT-001 11 of 12 Rev.12/18/12 Part VII: Owner/Operator Certification The owner/operatorand the individual(s) responsible for actually preparing the notification must sign this part. A notification will be considered incomplete unless all required signatures are provided. "I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on reasonable investigation, including my inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief. I understand that a false statement in the submitted information may be punishable as a criminal offense, in accordance with section 22a-6 of the General Statutes, pursuant to section 53a-157b of the General Statutes, and in accordance with any other applicable statute. I certify that I have completed a Certification of Financial Responsibility Form and such completed form is maintained on-site. I also certify that this underground storage tank notification is on complete and accurate forms as prescribed by the commissioner without alteration of the text." L Signatuife of OwnepfOperator Date V1 Name of Owner/Operator (p(int or type) Title (if applicable) Signature of Preparer (if different than above) Date Name of Preparer(print or type) Title (if applicable) ❑ Check here if additional signatures are required. If so, please reproduce this sheet and attach signed copies to this sheet. Note: Please submit a completed Underground Storage Tank Notification and all Supporting Documents to: CENTRAL PERMIT PROCESSING UNIT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM STREET HARTFORD, CT 06106-5127 A copy of all completed Notification Forms must be maintained on site and the most recent completed form must also be forwarded to the local fire marshal. If you have any questions, please contact the UST Program at 860-424-3374 or by e-mail DEERUSTFeeact.aov DEEP-UST-NOT-001 12 of 12 Rev. 12/18/12 UNDERGROUND STORAGE JPG.I of I STATE OF CONNECTICUT Department of Environmental Protection EPHM-6 NEW 10/85 2a FACILITY NOTIFICATION UNDERGROUND STORAGE FACILITIES PROGRAM 3. FOR STATE A.SITE I.D. , HAZARDOUS MATERIALS MANAGEMENT UNIT AGENCY USE ONLY Z 165 Capitol Avenue,Hartford,CT 06106 O ❑ FIRST _ _ _ B DATE RCVD BY D.E.P C.DATE ENTERED H la. NOTIFICATION - TEL. 556-4630 U SITE I.D. R�r N OR s PLEASE TYPE.ALL THREE COPIES MUST BE LEGIBLE! " rk GRID COORDINATES E DOES FACILITY MEET NEW REQUIRE ENT57 SUBSEQUENT (If checked, b. NOTIFICATION enter No.) Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form. Y ❑YES ❑N LOCATION SITE NAME NO.AND STREET NEAREST INTERSECTING STREET CITY OR TOWN STATE 5AATITUDE t LONGIT 4. OF FACILITY Mitchell_.Fuel-Co. a Inc. an Avenue P e e ad 41° 50 10 e� i720 30 r� BUSINESS NAME AND NO AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE 6. MAILING ADDRESS Mitchell Fuel Co. , Inc. 1209 Sullivan Avenue South Windsor CT 0 ( 203,644-2561 co NAME NO.AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE 0 7. FACILITY OWNER Mitchell _ South Windsor CTI 06074 ( 203)644-6524 i= U w 8. TYPE OF OWNER ® PRIVATE ❑ STATE ❑ MUNICIPAL ❑ FEDERAL(G.S.A.No. OPERATOR/CONTAC NAME NO AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE 9. PERSON John J. Mitchell Jr. 660 St one Road South Windsor CT 06074 if 201289-1484 10. I la. Ilb. 12a. 12 b.STATUS 13. TYPE OF 14. CONTENTS- 15.CONSTRUCTION 16.PROTECTION 17. INTEGRAL > DATE CONTENTS MATERIALS I RNAL b. EXTERNAL PIPING SYSTEM 18. 19. FAILURE TANK ID. DATE OF z— TOTAL p I EST.QUANTITY 1- CHEMICAL NAME OF PRINCIPAL Z o. b. DATE OF MONITORING DETERMINATION INSTALLATION "o CAPACITY Z w TANK U _ 00 V O O U Z Z _ INSTALLATION v e U I LEFT STORED 0 SUBSTANCE v w Q O p U 11 — p z 0 w O m 0 SYSTEM CONDUCTED? (Gals. O Q w LAST c Q .i 0 w a s b a_ > O v (not trade name.) w p_» w OU Goy < OR (Mo./Yr.) x a w Z a I (if any). w a p J L9 O = y— =w a O U i m= F 2 W _ 1{"YES",enter DATE" wxc O USED a s (Enter C.A.S. Noylf known) w ,�„i a E Q o f <� REPLACEMENT w m I (Gals.) w J S O f°w a O�o Z Z a 0 O Q O O'^ 2 z (Specify type and attach results). Z Q o (Mo./yr.) O J LL m J V a U 3 U a O n (Mo./Yr.) from list BI If"NO",enter"NO") X X Heating fuel#2 X X 5 C/75 1 t NO Example 5j75 30 5000 y y � fCl J V 1y h X h felt CrASI#7901h6 vie X I X E 7 7�60 U Example 7/60 8000 X $/78 Ke U 0 - Kerosene U W 20. HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? ® YES 22.CERTIFICATION: I certify under penalty of low that I have personally A URE 226 DATE SIGNED to examined and am familiar with the information submitted in this and all attached Z 21. COMMENTS: documents and that based on my inquiry of those individuals immediately responsible / ' 4,- O for obtaining the information,I believe that the submitted information is true, V (C» Uaccurate and complete.Penalties:any owner who knowingly foils to notify shall be 22d.OFFICIAL TITLE(of owner or authorized tL subject to a civil penalty not to exceed$I0,0D0 for each tank for which notification �ME(Type_gg.9iwrry— I representative). to is not given or for which false information is submitted. /� 1- - / / 1 f Tyr hl�l) �l ,11 \/ II ( ` COPY 2 . SEND TO LOCAL FIRE MARSHAL i STATE OF CONNECTICUT EPAV6 Rev 5/94 UNDERGROUND STORAGE PG Of I , FOR STATE A DATE ENTERED 2. Department of Environments!Protection �,r FACILITY NOTIFICATION UNDERGROUND STORAGE FACILITIES PROGRAM , � 3' AGENCY USE ONLY Q q� Z Bureau of Waste Management J`Nf ti, B.FEE BILLED C.FEE RECEIVED O 79 ELM STREET.Hartford,CT 06106-5127 1 a ❑ F NI RST OTIFICATION TEL.(860)424-3374 ' SITE I.D. D GRID COORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS? OR PLEASE TYPE OR PRINT.ALL THREE COPIES MUST BE LEGIBLE X Y ❑YES ElNO b SUBSEQUENT (if checked. - Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form. NOTIFICATION enter no. P 9 LOCATION SITE NAME NO.AND STREET NEAREST INTERSECTING STREET CITY OR TOWN STATE 5.LATITUDE LONGITUDE 4. OF FACILITY Mitchell Fuel ie Piers p Rc�ad o rr I o rr - - Av�at -_ BUSINESS NAME AND; NAME NO,AND STREET — CITY OR TOWN STATE ZI ODE TELEPHONE — 6. MAILING ADDRESS ` MitChell FU�1 ( I m NAME A S SR ZIC100171 TELEPHONE Z 7. FACILITY OWNER South Windsor - Drive40 Windy Hill I- — U 8. TYPE OF OWNER � PRIVATE I—' STATE ❑ MUNICIPAL ❑ FEDERAL(G.S.A. NO. w _ OPERATOR/CONTACT NAME NO AND STREET CITY OR TOWN _ STATE ZIP CODE TELEPHONE 9. PERSON IJohn J. Mitchell Jr. 63 Co try Club Road Bolton CT 0604 1 ( 860 10. 1la. 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 v CHEMICAL NAME OF PRINCIPAL (no E z z E z DATE OF MONITORING z ww I o rnw UO o INSTALLATION w A CAPACITY z U LEFT STORED w TANK Q o a o SUBSTANCE v v ° o w ° gm INSTALLATION o w a r= �- _ SYSTEM (if"YES enter"DATE" O I > �o v— w S¢1— w a w z OU W0- OU w m c�� (Mo.Yr.) a o (Gals.) o g (If any) o LAST aw¢a g o (not trade name) w O O cn =2 n Z J =w a a X.w =2 y — w� OR and attach results). w ? z° I (Gals.) USED ) a z w _ (Enter C.A.S.No.,if known rr~i w z< J J z o¢ �-1 u H¢ o 9 REPLACEMENT (Specify type (If"NO".enter"NO") Q- I cc (Mo./Yr.) J o co M o in D cU L) 0¢ O rn �� ¢=' ( ) ) Q. Mo. Yr from list B Example 5/75 30 5000 X X Heating fuel#2 X X H 3 H 5/75 U NO l; Example 7/60 — 8000 X 8/78 X I,I,I,-Tricloroethane X X E 7 W 7/60 U — p CAS#79016 Al 98 DO 2000 x % Diesel Fuel X X X D 6 W 8/98 T NO U o No Led Gas_ X 6 W 8 98 T so P U w to AlI 22.CERTIFICATION:I certify under nag of law that I have personal) examined 22 SIG TURE 22b.DATE SIGNED 20.HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? � YES �' penalty y 0 and am familiar with the information submitted in this and all attached documents and that o21.COMMENTS: based in i I / Veeder Root TLS- 300-C Monitoring, System y quryolthoseindivdualsimmediatalyresponsbleforobtainingtheinformation, 03 I believe that the submitted information is true,accurate and complete. U Penalties:an owner who knowingly fails to notify shall be subject to a civil penalty not to 22c.N ME(Type or P t1 22tl.OFF: �.L TITLE(or c.v. �� ;.r authorized w y g y y ( p y epresonfative). exceed$10.000 for each tank for which notification is not given or for which false information Is submitted. John J. Mitchell Jr. Vice President COPY 2: SEND TO LOCAL FIRE MARSHAL UNDERGROUND STORAGE Pc of STATE OF CONNECTICUT Deportment of Environmentol Protection EPHM-6 NEN 10/85 2 A.SITE I.D. FACILITY NOTIFICATION UNDERGROUND Q STORAGE FACILITIES PROGRAM 3. FOR STATE -- HAZARDOUS MATERIALS MANAGEMENT UNIT 165 Capitol Avenue,Hartford,CT 06106 AGENCY USE ONLY 0 FIRST' 0 __ - B.DATE RCVD BY D.E.P C.DATE ENTERED NOTIFICATION - -- TEL. 556-4630 U SITE I.D. N OR PLEASE TYPE. ALL THREE COPIES MUST BE LEGIBLE! r~�r�" D.GRID COORDINATES E.DOES FACILITY MEET NEW REQUIREMENTS) b. ❑ SUBSEQUENT (If checked, NOTIFICATION enter No i Refer to INSTRUCTIONS FOR FILING NOTIFICATION before completing form. X __ Y ❑YES ❑NO LOCATION SITE NAME NO.AND STREET NEAREST INTERSECTING STREET CITY OR TOWN STATE 51ATITUDE y ty i LONGITUDE Or It 4. OF FACILITY Ave• _ PieYCe R d $ Wi d4ff 1 BUSINESS NAME AND NAME NO.AND STREET CITY OR TOWN STATE ZIP CODE TELEPH45iW% 6. MAILING ADDRESS ]l Fuel_CO. , Inc. _ Nall Ave. -.___ South i 6,L; 2561 m NAME NO AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE Z 7. FACILITY OWNER 110 Arnnkfiald -St U - ��]] w 8. TYPE OF OWNER IR PRIVATE ❑ STATE ❑ MUNICIPAL ❑ FEDERAL(.S.A. No. OPERATOR/CONTACI NAME NO AND STREET CITY OR TOWN STATE ZIP CODE TELEPHONE 9. PERSON - CT 06074 ( 10. 1la I lb. 12o. 12 b.STATUS 13. TYPE OF 14. CONTENTS- 15.CONSTRUCTION I6.PROTECTION 17 INTEGRAL > DATE CONTENTS MATERIALS N RNAL b. EXTERNAL PIPING SYSTEM 18. 19. FAILURE DATE OF z TOTAL w o I EST.QUANTITY s- CHEMICAL NAME OF PRINCIPAL a. b. DATE OF MONITORING DETERMINATION TANK ID. INSTALLATION ° CAPACITY Z w TANK U H o U Q p U Z z u e U I LEFT STORED o SUBSTANCE u w Q z INSTALLATION w O p a J v U o O w O >m o a SYSTEM CONDUCTED. wa O¢ LAST of a:- o wa 0� a, .`e o_ (Gals.) o > O (not trade name.) N w - r a OR (Mn./Yr.) x o w a I (il any). w p J l7 O = y= ' w O U = i W < (If"YES",enter DATE" w � Z O USED a s F (Enter C.A.S. No. If known) W a o z ui a s x"' "- < w a Q Z I (Gals.) J w '' w an d O�o w Q O O ~~ O o Z O REPLACEMENT (Specify type and attach results). Z Q I (Mo./Yr.) O w U N LL ix ? j U a U 3 U� O d (Mo./Yr.) from list 8) If"NO",enter"NO") Example 5/75 30 5000 X X Heating fuel#2 X X H 5 5/75 U NO ple 7/60 8000 X 8/78 X I�I,1, CASI#79016 ne /� Exam X E 7 7/60 U NO U 0 8/84 - 550 X 5 86 X NoLead Gas X X E 8/84 U NO U W 3/84 - 275 X 5 86 X Waste Oil X X E 8 8/84 U NO osene X 7166 U NO 20. HAVE YOU ATTACHED SKETCH OF TANKS AND LOCATION? ❑ YES 22.CERTIFICATION: I certify under penalty of law that I have personally ° N 22b D; examined and am familiar with the information submitted in this and all attached Z 21. COMMENTS: documents and that based on my inquiry of those individuals immediately responsible 0 for obtaining the information,1 believe that the submitted information is true, H accurate and complete.Penalties:any owner who knowingly foils to notify shall be / 22, ''CIA[TITLE I owner or author ed is not given or for which false information is subm W subject to a civil penalty not to exceed$10,000 for each tank for which notification N ME(TyP1pr Penlafival. N - itte y/ J ,e /��r t LCOPY 2 . SEND TO LOCAL FIRE MARSHAL TheAeroALL=G4S PROPANE CERTIFICATION FORM Date elh4 b s Dealers Name Mjec e/t Foej C Address /,2o9 Town S b-n" crn C! Owners Name S (1) Certification Check List (2) Pumping Station and grounds condition , tzCe�P (3) Proper fence enclosure (YE /NO (4) In date fire extinguisher minimum 20# BC rated YES NO (5) Warning Signs Propane !f/NO 0 No Smoking O UN1075 Filling InstructionsO (6) Source of ignition while pumping YES NO (7) Use of gloves and eye protection YES NO (8) Check scales daily ES NO (9) Bulletin 118 posted E NO (10) Bulletin 117 posted 0/NO (11) Currant M. S.D. S. YE NO Comments:- PQ i lAn1 isckcpc& wal 1enop r-e S.-III A CERTIFIED PERSONNEL AUTHORIZED A GAS YS w Q6N41�l ME / to*. -I 1 3150 MAIN STREET, HARTFORD,CONNECTICUT 06120 (203)278-AFRO r i,• y� •'�!%.' _ _ - - a ♦ . . % -•fin'•' :•i }, - r~l - a _ -- ._. _ r - 1. ./` - \ . .. , ' -r - - _ 'r♦ 94 N/I= LAURA TOMLINSON �96 I '100 9 94 �'• ss kF:3'LSACTIUM TLICJ ALLAN a KATHERINE D. — - � �930 IO90 Ga:_ SOILTES_T,*., BOURN sAti 30'O q y ovw"1 EXSX7 O� 1 ` AnITION GAGAG8 ' k FF$05.0 �I•FACS-8 �SC,sfr:' �104MIN. .j1 CblrCr GV2Y .Ifin` Cl I _=DRIVEWAY �}°` �p�,� ')r�sr� �ot`r�T�°y / �M 4#499 LJ� 'r am,* 50' 13UILDING LINE s � _ Notifico�Ynderground Storage Tanks APR 0 7 2011 CPPU USE ONLY sr' App#: Please complete this entire form,where applicable, in Doc#' accordance with the instructions(DEP-UST-INST-001)to ensure the proper handling of your notification. Print or type Check M unless otherwise noted. Submit one notification form per site. Part I: Notification and Fee Type Check the appropriate box(es) identifying the notification type. 1. LOCATION of UST(s) // l Name of site: �.k./),0 l/ Kcte f Ca IUD Street Address or Location D iption: 12 D q -Eu 1.i r QA PJ City/Town: 5, ( State: C-T� Zip Code: Q 0 2. Site ID Number, if known: l 2 .. � f{� 3. This notification is for(check all that apply): Fee *Number of Tanks Total Fee= (a) (b) (a x b) An annual $100.00/per tank Z Zoo,--- ❑ fee exempt tanks $0 ❑ adding new UST system $100.00/per tank ❑ fee exempt tanks $0 ❑ adding an orphan UST system (newly $100.00/per tank discovered) ❑ fee exempt tanks $0 ❑ update/correction to owner/site info $0 ❑ update/correction to UST system info $0 ❑ Permanent Closure of an UST system $0 * Compartmentalized tanks are counted as one tank. *Total Fee *For municipalities, the 50%discount applies. The notification will not be processed without the fee. The fee shall be non-refundable and shall be paid by check or money order to the Department of Environmental Protection. DEP-UST-NOT-001 1 of 10 Rev. 02/18/11 f Part II: Owner/Operator Information If identifying an entity registered with the Secretary of the State, fill in the name exactly as it is shown on such registration. 1. @wry/Operator Name: Mailing Address: /aa City/Town: ©gi b�d SOS State: G D' Zip Code: 0607 y Business Phone:g&0.-4V-q 2g fxt.. Fax: Contact Person: S q-pA.e-, Phone: ext. Business Type(check one): private ❑ federal gov't ❑ state gov't ❑ local gov't ❑ tribal' Notification or fee is NOT required for UST systems located on tribal lands. ❑ Check if any co-owners. If so,attach additional sheet(s)with the required information as requested above. Owners interest in property or facility at which the proposed activity is to be located: (check all that apply) ❑ storage tank owner ❑ billing contact IR/Property owner ❑ storage tank operator ❑ facility owner/operator ❑ other(specify): 2. List primary contact person in charge of tanks, if different than the owner. Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext. Fax: Contact Person: Title: Email: 3. List storage tank operator, if different than the owner. Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext. Fax: Contact Person: Title: Email: 4. List billing contact, if different than the owner. Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext. Fax: Contact Person: Title: Email: DEP-UST-NOT-001 2 of 10 Rev.02/18/11 Part II: Owner/Operator Information (continued) S. Financial Responsibility Other than through state funds, check the applicable box(es) by the following mechanisms to identify how you have met financial responsibilities requirements. (check all that apply): ❑ Self Insurance ❑ Guarantee ❑ Bond Rating Test Commercial Insurance ❑ Surety Bond ❑ Trust Fund ❑ Risk Retention Group ❑ Letter of Credit ❑ Local Government ❑ Other Method (specify): Financial Test Part III: Site Information TYPE OF SITE (check all that apply): ❑ Air Taxi (Airline) ❑ Federal Non-Military Private ❑ Aircraft Owner ❑ Gas Station ❑ Railroad ❑ Auto Dealership ❑ Industrial ❑ Residential Q(Commercial ❑ Local Government ❑ School [Contractor ❑ Marina ❑ State ❑ Convenience Store ❑ Municipal ❑ State Government ❑ Farm ❑ Other ❑ Trucking/Transport ❑ Federal Petroleum Distributor ❑ Utilities ❑ Federal-Military DEP-UST-NOT-001 3 of 10 Rev. 02/18/11 Part IV: Underground Storage Tank Information Complete for.all tanks and piping at the subject location. If you have more than 5 tanks in one location, reproduce this Part and complete for additional tanks. Tank Identification Number Tank No•: Tank o.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Tank Construction 1. Status of Tank Currently in Use 211 ❑ ❑ ❑ Temporarily Closed ❑ ❑ ❑ ❑ ❑ Date Temporarily Closed Permanently Closed ❑ ❑ ❑ ❑ ❑ 2. Emergency Generator Use Only ❑ ❑ ❑ ❑ ❑ 3. Date of Installation of Tank(month/year) 4. Life Expectancy of Tank(years) '3 0 0 5. Estimated Total Capacity of Tank(gallons) 6. Substance Currently Stored in Tank(or last stored in the case of closed tanks) / fasoiine ❑ Ld" ❑ ❑ ❑ Diesel ❑ ❑ ❑ ❑ Kerosene ❑ ❑ ❑ ❑ ❑ Heating Oil(on-site consumption) ❑ Cl ❑ ❑ ❑ Heating Oil (for resale) ❑ ❑ ❑ ❑ ❑ Used Oil ❑ ❑ ❑ ❑ ❑ Gasohol ❑ ❑ ❑ ❑ ❑ Biofuel ❑ ❑ ❑ ❑ ❑ If Other,please specify here Hazardous Substance ❑ ❑ ❑ ❑ ❑ CERCLA name and/or CAS Number Mixture of Substances ❑ ❑ ❑ ❑ ❑ Please specify substances here 7. Material of Construction of Tank Asphalt Coated or Bare Steel ❑/ —❑/ ❑ El ❑ Coated and Cathodically Protected Steel(STI-P3) [�' �f ❑ ❑ ❑ Composite(Steel dad with Fiberglass) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Plastic Jacket) ❑ ❑ ❑ ❑ ❑ Composite(Steel with Urethane) ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ ❑ ❑ ❑ ❑ If Other(e.g.,concrete,etc.) (please specify) DEP-UST-NOT-001 4 of 10 Rev.02/18/11 Part IV: Underground Storage Tank Information (continued) Tank Identification Number Tank Tanrk NNoo.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ 7. Material of Construction of Tank(continued) Lined Interior ❑ ❑ ❑ ❑ ❑ Excavation Liner ❑ ❑ ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑ ❑ Tank Manufacturer 1 � Check box if tank has ever been repaired ❑ ❑ ❑ ❑ ❑ 8. Primary Release Detection-Tank Annual Precision Tightness Testing ❑ ❑ ❑ ❑ ❑ Tank Tightness Test with Inventory Control ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ ATG Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ ATG-CSLD—Continuous with Inventory ❑ ❑ ❑ Reconciliation/Control ATG-Static with Inventory ReconcikatkxVControl ❑ ❑ ❑ ❑ ❑ Monthly GroundwaterNapor Monitoring ❑ ❑ ❑ ❑ ❑ Manual Tank Gauging ❑ ❑ ❑ ❑ Cl Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Automatic Tank Gauging E2 2" ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method, please specify here Piping Construction 9. Piping Installation Date qu Q C! 10. Piping Material Bare Steel ❑ ❑ ❑ ❑ ❑ Galvanized Steel ❑ ❑ ❑ ❑ ❑ Epoxy Coated Steel ❑ ❑ ❑ Flexible Plastic ❑ ❑ ❑ ❑ ❑ No Piping associated with Tank or Above Ground Only ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic ❑ ❑ ❑ ❑ ❑ Semi-Rigid Plastic ❑ ❑ ❑ ❑ ❑ Copper ❑ ❑ ❑ ❑ ❑ Containment Sumps at Dispensers ❑ ❑ ❑ ❑ ❑ Containment Sumps at Tanks ❑ ❑ ❑ ❑ ❑ Metallic Fitting Isolated from Soil and Water —❑/ ❑/ ❑ ❑ ❑ Metallic Fitting Cathodically Protected f�" �7 ❑ ❑ ❑ DEP-UST-NOT-001 5 of 10 Rev.02/18/11 DEP-UST-NOT-001 6 of 10 Rev.02/18/11 Part IV: Underground Storage Tank Information (continued) Tank Identification Number Tan No.: Tank No.: Tank No.: Tank No.: Tank No.: 2- Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ 10. Piping Material (continued) Cathodically Protected (� ❑ ❑ ❑ Double Walled ❑ ❑ ❑ ❑ ❑ Unknown ❑ ❑ ❑ ❑ ❑ If Other,please specify here 11. Piping Type(must check one for each tank) Pressure ❑ ❑ ❑ ❑ ❑ "U.S."Suction(valve at tank) ❑ ❑ ❑ ❑ ❑ No Underground Product Piping or Gravity Feed Only ❑ ❑ ❑ ❑ ❑ "Safe"Suction(no valve at tank) W H/ ❑ ❑ ❑ Check box if piping has ever been repaired ❑ ❑ ❑ ❑ ❑ 12. Primary Release Detection-Piping Annual Precision Line Tightness Testing ❑ ❑ ❑ ❑ ❑ Continuous(Electronic)Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ Monthly Visual Interstitial Monitoring ❑ ❑ ❑ ❑ ❑ GroundwaterNapor Monitoring ❑ ❑ ❑ ❑ ❑ PLLD—Annual.I gph Leak Test ❑ ❑ ❑ ❑ ❑ PLLD—Monthly Elec.0.2gph Leak Testing —❑ ❑❑/ ❑ ❑ ❑ Precision Line Tightness Testing Every 3 years ❑ ❑ ❑ Statistical Inventory Reconciliation(SIR) ❑ ❑ ❑ ❑ ❑ Automatic Line Leak Detectors ❑ ❑ ❑ ❑ ❑ Electronic Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑ Mechanical Auto Line Leak Detectors ❑ ❑ ❑ ❑ ❑ No release detection required(see instructions) ❑ ❑ ❑ ❑ ❑ If Other Method, please specify here 13. Spill and Overfill Protection Overfill Device Installed Audible Alarm 03 K( ❑ ❑ ❑ Ball Float Device ❑ ❑ ❑ ❑ ❑ Flapper Device ❑ ❑ ❑ ❑ ❑ None ❑ ❑ ❑ ❑ ❑ Other(please specify) Spill Device Installed ❑ ❑ ❑ ❑ ❑ DEP-UST-NOT-001 7 of 10 Rev.02/18/11 Part V: Permanent Tank Closure Tank Identification Number Tank r 0.: Tan Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ , ❑ ❑ ❑ 1. General Information of Closed Tank Date of Installation(month/year) Estimated Total Capacity(gallons/year) Estimated date tank closed(month/day/year) (check one per tank): Tank was removed from ground ❑ ❑ ❑ ❑ ❑ Tank was closed in ground ❑ ❑ ❑ ❑ ❑ Tank filled with inert material ❑ ❑ ❑ ❑ ❑ Describe the inert fill material here 2. Estimated date the UST was last used for storing regulated substances(month/day/year) 3. Site Assessment Required Site Assessment Completed ❑ ❑ ❑ ❑ ❑ (If Yes,provide consultant/contractor information below) Consultant/Contractor Name(s) Consultant/Contractor Addresses(s) Consultant/Contractor Phone(s) Soil Samples Collected and Analyzed for one or more of El ❑ Cl El El following: VOCs,SVOCs,Metals,ETPH Groundwater Encountered During Assessment ❑ ❑ ❑ ❑ ❑ Groundwater Samples Collected and Analyzed for one or ❑ ❑ ❑ ❑ ❑ more of the following: VOCs,SVOCs,Metals,ETPH 'Soil Samples had Constituents of Concern above the folbwing RSR Criteria: GA PMC ❑ ❑ ❑ ❑ ❑ GB PMC ❑ ❑ ❑ ❑ ❑ Res DEC ❑ ❑ ❑ ❑ ❑ I/C DEC ❑ ❑ ❑ ❑ ❑ •If any boxes were checked,include a table summarizing the data and highlighting the exceedances (See R.C.S.A. Sections 22a-133k-1 through 3 for definitions). 'Groundwater Samples had Constituents of Concern above the following RSR Criteria: GWPC ❑ ❑ ❑ ❑ ❑ SWPC ❑ ❑ ❑ ❑ Cl Res GWVC ❑ ❑ ❑ ❑ ❑ I/C GWVC ❑ ❑ ❑ ❑ ❑ If any boxes were checked,include a table summarizing the data and highlighting the exceedances (See R.C.S.A. Sections 22a-133k-1 through 3 for definitions). DEP-UST-NOT-001 8 of 10 Rev. 02/18/11 Part V: Permanent Tank Closure (continued) Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a compartmentalized tank ❑ ❑ ❑ ❑ ❑ Remedial Actions Recommended by Environmental Consultant/Contractor ❑ ❑ ❑ ❑ ❑ If box is checked,a closure report must be submitted to the LUST Coordination Program for evaluation. Remedial Actions Completed If box is checked,a closure report must be submitted to the ❑ ❑ ❑ ❑ ❑ LUST Coordination Program for evaluation. Part VI: Certification of Installation Complete within 30 days of installing an UST or adding an UST system to an existing notification. If you have more than 5 tanks in one location, reproduce this part and complete for additional tanks. Tank Identification Number Tank No.: Tank No.: Tank No.: Tank No.: Tank No.: Part of a Compartmentalized Tank ❑ ❑ ❑ ❑ ❑ Installer of tank and piping must check all that apply ❑ ❑ ❑ ❑ ❑ Installer certified by tank and piping manufacturers ❑ ❑ ❑ ❑ ❑ Installation inspected by a registered engineer ❑ ❑ ❑ ❑ ❑ Installation inspected and approved by implementing ❑ ❑ ❑ ❑ ❑ agency Manufacturer's installation checklists have been ❑ ❑ ❑ ❑ ❑ completed If Other Method, please specify here Provide signature of UST Installer to certify proper installation of subject UST System. Signature of UST Installer Date Name of UST Installer (print or type) Title Company Name DEP-UST-NOT-001 9 of 10 Rev.02/18/11 Part VII: Owner/Operator Certification The owner/operator and the individual(s) responsible for actually preparing the notification must sign this part. A notification will be considered incomplete unless all required signatures are provided. "I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on reasonable investigation, including my inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief. I understand that a false statement in the submitted information may be punishable as a criminal offense, in accordance with section 22a-6 of the General Statutes, pursuant to section 53a-157b of the General Statutes, and in accordance with any other applicable statute. I certify that this underground storage tank notification is on complete and accurate forms as prescribed by the commissioner without alteration of the text." nd"6-, 1 Signat re of Owne Operato Date fl�e Ail Name of Owner/Operator(print or type) Title(if applicable) Signature of Preparer(if different than above) Date Name of Preparer(print or type) Title(if applicable) ❑ Check here if additional signatures are required. If so, please reproduce this sheet and attach signed copies to this sheet. Note: Please submit a completed Underground Storage Tank Notification and all Supporting Documents to: CENTRAL PERMIT PROCESSING UNIT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM STREET HARTFORD, CT 06106-5127 A copy of this completed Notification Form must also be forwarded to the local fire marshal. If you have any questions, please contact the UST Program at 860-424-3374 or by e-mail (DEP.USTFeeCDct.gov) DEP-UST-NOT-001 10 of 10 Rev.02/18/11 9 �92 4 9/8 N/F LAURA TOMLINSON --'� 96 / /100 92/ � 323T 94 0, 75 LF_3'LEACHING TENCH \ N/F ALLAN H KATHERINE D. — — — �FL�•o-' FL 980 1000 GAL SCIL TESTS BOURN s� , rlc _ / D' TAB NR- 1 1 30-o � PROPOSED EXIXT. ' ADDITION GAGACE - 102 II I FF 105.8 .FF 105.8 ----j04 i 12!'2` �•�12"'2 106 1 / DRIVEWAY I ' N e1<.1209 102.L��e 4t-199 ^{� 50' BUILDING LINE 98 / 104 ►00 -- -- -- 423 -- SULLIVAN AVENUE CONN. ROUTE 194 LEGEND Septic System Design EXISTING CONTOURS -- —— Deep Test Pere Test Design - PROPOSED CONTOURS 0-6" loam 1"'= 25 minutes Use 1000 gallon septic tank 6-54" sandy clay Loading- 1 gpd/sf leachi_ng area �w-at 36 5 employees at 50 gp = 250 gPd2_x13 PLAN OF PROPOSED ADDITION FOR Required 250 sf MITCHELL FUEL COMPANY .fit;:`} �+ Use 75 if- 3' wide t ench, µ SULLIVAN AVENUE SOUTH WINDSOR CONN. EMIL W . LUCEK ASSOCIATES NO. REVISIONS DATE SCALE I"= 40' DATE 10- 1-T8 CONSULTING ENGINEERS ri 5 OAXLAND ROAD DRAWN A.V, H. CHECKER E.W.L. ,$ SOUTH WINDSOR. CONN. r;T�Y 203-644-2474 �n PROJECT 78'22i SHEET CERTIFIED SUBSTANTIALLY CORRECT DEGREE UE ACCURACY -A- 2 07 45 c E77 w" - A P P R OV E D TOWN OF SOUTH WINDSO.--! SC�l ENGINEERING DEPARTMENT DATE: 61 - IC7 SIG.: 1900930 TOWN OF SOUTH WINDSOR, CT PERMIT NUMBER BUILDING PERMIT DATE: 12/16/2019 GIS ID: 87301209 FEE: 108.00 MUNIS APPLICATION# 201902850 BUILDING DESCRIPTION: APPLICANT LOCATION NAME: DZEN SHEET METAL CONTRACTORS,INC. ADDRESS: 1209 SULLIVAN AVENUE ADDRESS: 74 RANNEY STREET OWNER: MITCHELL JOHN J SR PO BOX 1163 EAST HARTFORD,CT 06108 DESCRIPTION OF WORK: REMOVE AND REPLACE ROOF 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 12/16/2019 11:50 AM TILE FEE ABOVE INCLUDES A$0.26 PER THOUSAND CT STATE EDUCATION SURCHARGE