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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. i1 PARCEL NO. a
I
ADDRESS OF TANK, �V 1 LLAGE:
Numb.�r Ytr��! , �
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) .
OWNERI NAME: f�' �` t C_ lf_. 1� I (fyJ?6-1 PHONE:
INSTALLATION DATE s N ;)q Mom- BY: 6?�b
INSTALLER ADDRESS: /M G'(k CERT.NO. `2f )4
=-*TAN.K L-OCAT I O.N: .:��-__ �"c�C+��f:t.
i i_, i 1 x ?GCE i�evna r0 t InnX
CAPACITY �;l6L,"0 TYPE OF TANK ��1 t." AGE 21 YRS. FUEL/..CHEMICAL
TESTING CERTIFICaATI.ON [ V]'�PASS r[ ] FAIL DATEr�= r�
LEAK_ DETECTION C 7 CHECK IF N/A TYPE/.BRANDS ilroI(I {( a 1 fr 't�' ;4e I(.,
ZONE OF CONTRIBUTION '
YES ^-.[ °]A�NO�. ; DATE`TO BE REMOVED ".}
t
FIRE DEPT. PERMIT ISSUED C A YES C ] NO,._,._DATE,., / r���lqf`31
CONSERVATION j k' IFf A DATE <
BOARD OF HEALT TAG NO.
.*, ,PLEASE PROVIDE A SKETCH SHOWING THE -TANK LOCATION ON THE BACK OF THIS CARD
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{ = � Commonwealth of Massachusetts - Department of Fire Service:
Executive Office of Public Safety - UST Regulatory Compliance Ur.
Notification for Storage Tanks Regulated Under 527 CMR 9.00
Forward completed form,signed by local fire department,to: Mass.UST Program NEW
of Fire Services,P.O.Box 1025-State Rd.,Stow,MA 01775 Ait's 1.�
YAe`1�'fiS
Use Form FP-29OR to notify of tank removals or closures in place. li ^(dt.
Dina
Telephone(978)567-3710 95�41ak1 6(Fire Department retains one copy of FP 290) 'I1�t )v `PiPee Sig. Q =
A. New Facility see Instructions #1 B. Amended VC.' Renewal
INSTRUCTIONS: Form FP-290(Notification for Aboveground and Underground Storage Tanks)is to be completed for each
location containing underground or aboveground storage tanks regulated under 527 CMR 9.00. It more than five tanks are A. Facility Number
owned at this location,photocopy the following pages and staple continuation sheets to the form. The FP-290 must be
completed in duplicate. Although the form may be photocopied,the facility owner or owner's representative must sign each
copy separately;photocopied signatures are not sufficient. Both copies of the FP-290 are to be forwarded to the local B. Date Entered
fire department,who will check all information and certify the forms. The fire department will retain one copy of the FP-
290 for its records,and the facility owner shall be responsible for forwarding the other copy to the Dept.of Fire
Services at the address above. The local fire department will issue the permit portion of the FP-290;however,registration C. Clerk's Initials
is not complete until the FP-290 Is received and checked by t e UST Regulatory Compliance Unit. All questions on this form
are to be answered. Incomplete forms will be returned. D. Comments
1 to
Facility'means a tank or tanks located a site where tanks have not been previously located.
2'Facility street address'must include both a street number and a street name. Post office box numbers are not
acceptable,
and will cause a registration to be returned. If geographic location of facility is not provided,please indicate distance and
direction from closest intersection,e.g.,(facility at 199 North Street is located)400 yards southeast of Commons Road
(intersection).
GENERAL
• •
Notification Requined Exception: (a)a farm or residential tank of 1,100 gallons or less capacity used for storing
Fire Prevention Forth FP-290 is to be used as Notification,Registration and motor fuel for noncommercial purposes,or(b)a tank used for storing heating oil for
consumptive use on the promises where stored are not required to be registered under 527
Pemnit for aboveground and underground storage tanks and tank facilities
CMR 9.00.
regulated under 527 Code of Massachusetts Regulations 9.00. No regulated
aboveground or underground storage tank facility shall be installed,maintained, Penalties: Any owner who knowingly fails to notify or submits false information shall be
replaced,substantially modified or removed without a perrttit(FP-290)issued by subject to a civil penalty not to exceed$25,000 for each tank for which notification is not
the head of the local fire department. The owner of any storage facility shall given or for which false information is submitted. (MGL Chapter 148,section 38H,527
within seven working days notify the head of the local fire department and the
?Dept.of Fire Services of any change in the name,address,or telephone Aboveground Storage Tanks
number of the owner or operator of a storage facility subject to regulation by 527 CMR 9.00 requires the registration of any aboveground storage tank which meets the
Chapter 148,Mass.General Law and by 527 CMR 9.00. following definition: a horizontal or vertical tank,equal to or less that 10,000 gallons
capacity,that is intended for fixed installation without back fill above or below grade,and is
Underground Storage Tanks used for the storage of Hazardous Substances,Hazardous Wastes,or Flammable or
Each owner of an underground tank first put into operation on or after Jan.1, Combustible Liquids.
1991,shall,with thirty days after the tank is first put into operation,notify the
Department of Fire Services(the department)of the existence of such tank, Exception#1: Aboveground tanks of more that 10,000 gallons capacity regulated by 520
specifying,to the extent known,the owner of the tank,date of installation, CMR 12.00(Requirements for the Installation of Tanks Containing Fluids Other Tan Water
capacity,type,location,and uses of such tank. By no later that Jan.31,1991, in Excess of 10,000 Gallons)are not required to be registered under 527 CMR 9.00.
each owner of an underground storage tank that was in operation at any time
after Jan.1,1974,regardless of whether or not such tank was removed from Exception#2: (a) a farm or residential tank of 1,100 gallons or less capacity used for
beneath the surface of the ground at any time,shall notify the department of the storing motor fuel for noncommercial purposes,or(b)a tank used for storing heating oil for
existence of such tank,specifying,to the extent know,the owner of the tank, consumptive use on the premises where stored are not required to be registered under 527
date of installation,capacity,type,and location of the tank,and the type and Penalties: Any person who knowingly violates any rule or regulation made by the Board of
quantity of substances stored in such tank,or which were stored in such tank Fire Prevention Regulations shall,except as otherwise provided,be punished by a fine of
before the tank ceased being in operation it the tank was removed from not less than one hundred dollars nor more that one thousand dollars. (MGL,Chapter
beneath the surface of the ground prior to the submittal of such notice to the 148,section 1OB,and 527 CMR 9.00)
department. Such notice shall also specify,to the extent known,the date the Where to Notify? Two completed notification forms should be signed by both the tank
surface of the ground prior to the submittal of such notice to the department. 8 owner and the local fire department. One copy will be retained by the fire department,and
the tank was abandoned beneath the surface of the ground prior to the submittal the tank owner shall send a separate copy to the address at the top of this page.
of such notice to the department,such notice shall also specify,to the extent
known to the owner or operator,the date the tank was abandoned in the ground When to Nofity? 1.Owners of storage tanks in use or that have been taken out of
and all methods used to stabilize the tank after the tank ceased being in operation must notify within thirty days.
operation.
Owners and Operators of Regulated Storage Tank Systems must maintain records
certifying that all leak detection,inventory control and tightness testing requirements for
the Regulated Storage tank System are current. These records must be readily available
for inspection.
I. Ownership of Tank(s) II. Location of Tank(s)
Owner Name(Corporation,Individual,Public Agency,or Other Entity) If known,give the geographic location of tanks by degrees,minutes,and
seconds. Example: Lat.42,36,12 N Long.65,24,17 W
Bell Atlantic
Latitude Longitude
125 High Street -
Street Address Dletarxce end directbn Win-closest-Intersection Isee Instnxtion W2
Room 1006 (Bell Atlantic 532407
r
Facility Nemeor Camnarry Site iderNfler.-as eoclicable
Boston MA 02110 49 Ocean Street 1 ( % d4 . ,+
city State Tic Code Streedf Address M.-G Box not axeotatile=see inatruelloris#21 ``�'rll
Suffolk Hyannis jNq 02601G�e®
County city stat ®�7J0 Co` '
(617)743-7123 04-1664-340 BARNSTABLE �
Phone Number(Include Area Code) Owners EmDlover Federal to A Countv
FP-290(revised 11l96) \,it Page 1
III. TYPE OF OWNER IV. INDIAN LANDS
❑ Federal Government ❑Commercial ❑Tanks are located on land within an Indian Reservation or on
❑ State Government (storage and sale) other trust lands.
0 Private ❑Tanks are owned by native American nation,tribe,or individual.
❑ Local Government (storage and use)
V. TYPE OF FACILITY
Select the Appropriate Facility Description: (check all that apply)
Gas Station Marina Trucking/Transport
Petroleum Distributor Railroad X Utilities
Airport Federal-Military Residential
Aircraft Owner Industrial Farm
Vehicle Dealership Contractor Other(explain)
VI. CONTACT PERSON IN CHARGE OF TANKS
Name: ffiR. 1EA D1S Qz Address: Phone Number(include area code):
Job Title: Environmental Specialist 125 High Street Room 1040 Home:
Boston,MA 02110 Business: (617)743-7123
VII. FINANCIAL RESPONSIBILITY
I have met the financial responsibility requirements in accordance with 527 CMR 9.00.
r-————————————-T——————————————r-—————————————
jCheck all that apply:
0 Self Insurance ❑ Guarantee ❑ Letter of Credit
❑ Commercial Insurance ❑ Surety Bond ❑ Trust Fund
❑ Risk Retention Group i ❑ State Fund i ❑ Other Method Allowed-Specify
VIII. ENVIRONMENTAL SITE INFORMATION
This information should be available from local health agent,conservation commission,or planning department.
1. Tank site located in wellhead protection area ❑ Yes ❑No 0 Unknown
2. Tank site located in surface drinking water supply protection area ❑Yes ❑No 0 Unknown
3. Tank site located within 100 feet of a wetland ❑ Yes ❑No Unknown
4. Tank site located within 300 feet of a stream or water body ❑Yes ❑No ❑x unknown
IX. DESCRIPTION OF STORAGE TANKS AND PIPING (COMPLETE FOR EACH TANK AT THIS LOCATION)
Tank Identification Number Tank No. Tank No. Tank No. Tank No. Tank No.
1. Tank status
a. Tank mfr's serial# (if known)
b. Currently in Use
c. Temporarily Out of Use (Start Date)
d. Permanently Out of Use 0 0 0 0
e. Aboveground storage tank (AST)or
Underground storage tank (UST) ❑ 'sT ❑AsT AST ❑usT ❑AST❑UST ❑AST❑UST ❑AST ❑UST
2. Date of Installation (mo./day/yr.) I- I_ L
3. Estimated Total Capacity (gallons) 0
FP-290(revised 11/96) Page 2
Tank Identification Number(cont.) Tank No._,�_ Tank No. Tank No. Tank No. Tank No.
4. Substance Currently or Last Stored
a. Gasoline
Motor vehicle or other use ❑ MV ❑ Marina ❑ MV ❑ Marina ❑ MV O Marina ❑ MV ❑Marina ❑ MV ❑ Marina
❑other ❑other ❑other ❑other ❑other
b. Diesel
Motor vehicle or other use ❑ MV arina ❑MV ❑ Marina ❑ MV ❑ Marina ❑ MV ❑ Marina ❑ MV ❑ Marina
other ❑other ❑other ❑other u other
c. Kerosene
d. Fuei Oil* j
"Consumptive Use"tanks need not be registered.
Consumptive Use'fuel used exclusively for area
heating and/or hot water.
e. Waste Oil 0 0 E:::= 0
f.Other, Please specify
---------------- ---- ----- ---- ----- ----
Hazardous Substance
(other than 4a thru 4e above)
CERCLA name and/or
CAS number
---------------- ---- ----- ---- ----- ----
Mixture of Substances 0 0 0 0 0
Please specify
5. Material of Construction-Tank(mark only on )
Bare steel (includes asphalt, galvanized
and epoxy coated) 0 0 0 7 0
Cathodically protected steel 0 0 0 0 0
Composite (steel with fiberglass) 0 0 0
Fiberglass reinforced plastic (FRP)
Concrete
Unknown
Other
Please specify
6.Type of Construction-Tank i
(mark only one)
Single walled
Double walled 0 0 0
Unknown
Other 0 0
Please specify
Is tank lined? C Yes No ❑Yes C No El C No ❑Yes C No C Yes C No
Does tank have excavation liner? 0 Yes V., No 0 Yes 0 No ❑ Yes 0 No 0 Yes 0 No 0 Yes No
Tank Identification Number(cont.) Tank No.,j Tank No. Tank No. Tank No. Tank No. '
7. Material of Construction-Piping(mark only one
Bare steel (includes asphalt, galvanized
and epoxy coated)
Cathodically protected steel 0 0
Fiberglass reinforced plastic (FRP) 0 ��
Flexible [ 0
Copper
Unknown
Other
Please specify A,
8. Type of Constriction-Piping(marls only one)
Single walled
Double walled
Unknown
Other
Please specify
Has piping been repaired? ❑Yes R o ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No ❑ Yes ❑ No
Is piping gravity feed? ❑ Yes 9 No ❑Yes ❑ No ❑ Yes ❑ No ❑Yes No C Yes C No
Date
X. CERTIFICATION OF COMPLIANCE
1. Installation
A. Installer certified by tank and piping
manufacturers
B. Installer certified or licensed by the
implementing agency
C.Installation inspected by a registered
engineer
D.Installation inspected and approved by
the implementing agency
E. Manufacturers' installation checklists
have been completed
F. Another method allowed by 527 CMR
9.00. Please specify
2. Tank Leak Detection Tank Tank Tank Tank Tank
(mark only one)
A. Double-wall tank- Interstitial monitoring
B.Approved in-tank monitor
C.Soil vapor monitoring (check one below) a
❑ Monthly ❑ Continuous
E. Inventory record-keeping and tank testing
F. Other method allowed by 527 CMR 9.00.
Please specify
P-?9n frevisad 1 V961
Tank Identification Number(cont.) Tank No.—a Tank No. Tank No. Tank No. Tank No.
3. Pi'pring Leak Detection (mark only one) Piping Piping Piping Piping Piping
A.Pressurized oo
a. Interstitial space monitor ❑ ❑ ❑ ❑
b. Product line leak detector ❑ ❑ ❑ ❑ ❑
(mark all that apply below)
Automatic flow restrictor'
Automatic shut-off device"
G Continuous alarm'
Also requires annual test of device and
piping tightness test or monthly vapor
monitoring of soil.
B. Suction: Check valve at tank only El ❑ ❑ ❑
(Requires interstitial space monitor or
line tightness test every three years)
❑ Interstitial space monitor
❑ Line tightness test
C. Suction: Check valve at dispenser only ❑ El
❑
(No monitor required) ❑
D. Other method allowed by 527 CMR
9.00. Please specify
4. Date of last tightness test (tank& piping)
5. Gravity feed piping ❑ ❑ ❑ ❑ ❑
6. Spill containment and overfill protection Tank Tank Tank Tank Tank
A. Spill containment device installed ❑ ❑ ❑ ❑
B. Overfill prevention device installed ❑ ❑ ❑ ❑
7. Daily !nventory Control (mark only one)
A. Manual gauging by stick and records
reconciliation ❑ ❑ ❑ ❑ ❑
B. Mechanical tank gauge and records ❑ ❑ ❑ ❑ ❑
reconciliation
C. Automatic gauging system ❑
8. Cathodic Protection (if applicable)
Tank Piping Tank Piping Tank Piping Tank Piping Tank Piping
A. Sacrificial Anode Type ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 11
B. Impressed Current Type ❑ ❑ ❑ ❑ ❑
C. Date of Last Test
1;�/4MM/
Certification of Compliance No.:
XI. CERTIFICATION (Read and sign after completing all sections)
NOTE:Both the copy being sent to the Dept.of Fire Services and the copy retained by the local fire department must be signed separately. A photocopied signature will not be
accepted on either document.
I declare under penalty of perjury that I have personally examined and am familiar with the information submitted in this and all attached documents,and that based on my
inquiry of those individuals immediately responsible for obtaining the information,1 believe tha a sub itted informatio 's true,ac-QmVeWcomplete.
i Name and official title of owner or owner's authorized representative(Print) Signature: Date:
The Commonwealth of Massachusetts �s
Executive Office of Health and Human Services 01/5 '
Department of Public Health
f
Radiation Control Program
174 Portland Street, 5th Floor, Boston, MA 02114
ARGEO PAUL CELLUCCI (617) 727-6214 (617) 727-2098 - Fax
GOVERNOR
JANE SWIFT
LIEUTENANT GOVERNOR
WILLIAM D.O'LEARY
SECRETARY
HOWARD K.KOH,MD,MPH
COMMISSIONER
July 22, 1999
Dan Goulet
Telecorp PCS, L.L.C.
10 Tara Boulevard, Suite 500
Nashua,NH 03062
RE: PCS
Dear Mr. Goulet:
Pursuant to your notification of July 15, 1999,this is to advise you that approval,under the
provisions of 105 CMR 122.021 has been granted to maintain the personal communication
services facility located at 49 Ocean Street in Hyannis,Massachusetts.
Should you have any questions,please contact Robert T. Watkins at(617) 727-6214.
Sincerely,
Robert M. Hallisey, Director
Radiation Control Program j
cc: Hyannis Board of Health
Cape Cod Commission
RMH/RTW/jc
A. EUGENE SULLIVAN, P.E.-PRESIDENT ASSOCIATES
ROBERT W. SULLIVAN, P.E.-TREASURER WALTER S. HARRINGTON, P.E.
ROBERT L. HOUGH, P.E.
ROBERT W. SULLIVAN, INC.
• SANITARY AND FIRE PROTECTION ENGINEERS
38 NEWBURY STREET, BOSTON, MASS. 02116
TELEPHONES COPLEY 7-5914 - 7-5915 - 7-5916
January 23, 1969
Town of Barnstable
Public Health Department
Barnstable, Massachusetts
Attention: Mr. Nurray
Gentlemen:
Re: Sewage Holding Tank
New England Telephone & Telegraph Company
Telephone Exchange Building Addition
Main Street - Barnstable, Massachusetts
At the request of-Desmond and Lord, Architects,
6 Beacon Street, Boston, Massachusetts, we have prepared the °
enclosed Sewage System Drawing No. SD-1 dated January 23, 1969,
in accordance with their instructions and are submitting it
for your approval and comments. Briefly it consists of a
concrete holding tank with facilities for indicating the
liquid level in the tank at all times and a warning light to
indicate that pumping is required.
Please contact us if there are any questions.
Very truly yours,
Robert W.. S ?1ivian, _Inc.
WSH:j 1 f
Enc.
cc: , Desmond and Lord
Mr. Thomas Amsler
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