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HomeMy WebLinkAbout0151 PINE AVENUE - Health � , 3Q�i � l y� l I-��Z i'(1�1'�� �- � � (� ,. ._. TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: ' vl 4 /`�'`�` lY � s��� �iI MAP NO. PARCEL NO. , OWNER NAME: AM// t' � ��. �l �G��i��c "'" VILLAGE: INSTALLATION DATE: / f� BY: / � i J � — I (�'�C� (� vr7 9 7 TANK INFORMATION LOCATION OF TANK: CAPACITY I1 TYPE AGE _Z&FUEL/CHEMICAL �r4-- r rT r TESTING CERTIFICATION C ] PASS 7C ] FAIL DATE -. LEAK DETECTION C7 CHECK IF N/A TYPE/BRAND, /} E rXJ ZONE OF CONTRIBUTION C ] YES C�] NO ' .DATE TO BE REMOVED FIRE DEPT. PERMIT 'ISSUED C ] YES C ] NO DATE CONSERVATION CHECK IF` N/A.- T DATE BOARD OF HEALTH TAG NO ]C JC ]C J DATE / Allec?, f PLEASE, PROVIDE. A" SKETCH}t.SHOWING_.;THE TANK.LOCAT'ION ON THE, BACK OF THIS CARD f - 2 ph hlfa,s' t� Y �dM 1 � .:,, ~ .,• • f •,,'"+s• 't ri St �,�e a[t ``s.._1:._ •a'- a, - �w .+ Ii. :.'�...Y « FIRE DEPT. STATE USE ONLY CER1 OICn ION _✓ LD.Number Submit to: LOCAL FIRE� DEPARTMENT Date R V ve i . -.'.-w,Cv-+'�"^r^'^ .; ..s .r.. • • ..3 s,�z kb '*.A�.�Y:zx +�:`�'1. Notification is required b� Federal law for all underground tanks that have been 4. pipeline lacilitic+ lincluding gathering lines) regulated under the \;tuna; Ga+ used to store regulated substances since January 1,1974,that are in the ground as of Pipeline Salcly Act of 1968.or the Naiardous Liquid Pipclnu•Salcts Act oI 1979.of May 8,1986,or that are brought into use after May 8,1986.The information requested chichi+an lot ra+tate pipeline facililc regulated under State lasus: is required by Section 9002of tile Resource Conservation and Recovery Act,(RCRA), 5.surfacc impoundments,pits.ponds.orlagoons: as amended. 6.+torm'watcr or ssastc Hato collection ssstcros: The primary purpose of this no6fic;uion program is to locate and evaluate under- 7.Ilo\s-through process tanks: ground wanks that stun or base stored perolcum or ha arduus substances. It is 8.liquid traps or associated gathering linesdireclly related to oil orgasproduc•tionand expected that the information you preside will be based on reasonahk available g:tithe rag lank sit records.or,in the absence of sucll records.\our knowledge.belief,or recollection. 9. storage tanks situated in an underground area (such as a basement. cellar. mincssorking,drill.shaft.or tunnel)if the storage tank is situated upon or abuse the Who Must Notify? Section 9W2 of RCRA. as amended. requires that, unless surlace of the Iloor. exempted,owners of underground tanks that store regulated substances must notify designated State or local agencies of the existence of their tanks.Owner means= What Substances Are Covered? l hc-notilicatiun requirement,appls to under- (a) in the case of an underground storage tank in use on November 8. 1984.or, ground storage tanks that contain regulated substances.l Ilk includes am+uh+ranee brought into use after that date,an% person who owns:m underground-storage tank. defined a+ haiardous in section 101 (14) of the Comprchcnsi\c F_m irunmcmal used for the storage.use,or dispensing of regulated substances,and Response.Compensation and Liability Act of 19801CF R('I.A).%% uh the esceptinn of (b) in the case of am underground storage lank in use before Nuscmbcr 8. 1984• those substances regulated as haiardous s+asic under Subtitle C of RCRA. It also but no longer ip use on that date.am person svho ossned such tank immediately before includes petroleum.e.g.,crude oil or anv fraction thereof tshich is liquid at standard the discontinuation of its use. conditions of temperature and pressure(00 degrees Fahrenheit and 14.7 pounds per \That Tanks Are Included? Underground storage tank is defined as anv one or square inch absolute). combination of tanks that(1)is used to contain an accumulation of"regulated sub- Where To Notify? Completed notification forms should he sent to the address stances."and(2)whose solume(including connected underground piping)is 10 i or given at the top of this page. more beneath the ground.Some examples are.underground tanks storing:1.gasoline. used oil,or diesel fuel.and 2.industrial sokcnu.pesticides.herbicides or fumigants. When To Notify? I.Osvncn of underground storage tanks in rue or that base been What tanks taken out of operation after.Ianuar\ 1. 1974,hill still in the ground.must notify bt Wh notiItu Other tanks excluded from notification are:nks Are Excluded? Tanks rcnuncd from the ground are not subject to Mav 8. 1986.2.Oil ncrs ssho bring underground storage tanks into use after htac_ 8. 1986.must notify within 30 days ol:bringing the tanks into use. 1.farm or residential tanks of'1.100kallons or less capacity used for storing motor fuel for noncommercial purposes; Penalties: Any owner who knowingly fails to notify or submits false information 2.tanksusedforstoringheatingoilforconsumpiideuseonthepremiseswherestorcd: shall be subject to a civil penalty not to exceed S10,000 for each tank for which 3.septic tanks: notification is not given or for which false information is submitted. t ..f t - 4 •d l • «t.•,r.;ti +. .�t: „- -y: .,+ yn:. y i t ... t Please type or print in ink all items except"signature"in Section V.This form must by completed for Indicate number of each location containing underground storage tanks.If more than 5 tanks are owned at this location, continuation sheets photocopy the re%erse side,and staple continuation sheets to,this form. � attached --•~ _ , .•Yi�' —..+.�+�s^ -� x 0._ r t , - u AL. ai, i = 7.j :';t ;, �•.^+..+rq�'r __.'� r Owner Name(Corporation,Individual,Public Agency,or Other Entity) (If same as Section 1,mark box here) i / nn � ,yA,f/ C y� �� ���r7 p(" Facility Name or Company Site Identifier,as applicable Street Add�I.e�s_ A � t� J/t/° S/ r C ty Street Address or State Road,as applicable C'tp State ZIP Code "County wh /W l Ar/e Code Phone Nurryber i City(nearest) State ZIP Code Type of Owner (A°ark all that apply®J Private.or Indicate Mark box here if tank(s) ® Current ❑ State or Local Gov't ❑ Corporate number of are located on land within El Former El Federal Gov't El tanks at this an Indian reservation or (GSA facility I.D.no. uncertain location on other Indian trust lands i ter. Name(If same as Section I,mark box here Job Title Area Code Phone Number ❑ Mark box here only if this is an amended or subsequent notification for this location. A ' k7. I certify under penalty of law 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, I believe that the submitted information is true,accurate,and complete. Name and official title of owner or owner's authorized representative gnature Date qigned - .• -TES. a M. •? 1 �,�I.PJ.}r7.! r'' � � _ _ ti 'r FormrF.P. 290�Part 21 Pit at,1 /S6�ct.cc. .. �L.. 1 Owner Name(from Section 1)_. ocation(from Section 11) Page No. of Pages r Tank Identification No.(e.g.,ABC-123),or Tank No. Tank No. Tank No. Tank No. Tank No. Arbitrarily Assigned Sequential Number(e.g.,1,2,3...) 1.Status of Tank Currently in Use 0 0 (Mark all that apply®) Temporarily Out of Use o 0 0 0 Permanently Out of Use Brought into Use after 5/8/86 2.Estimated Age(Years) 3.Estimated Total.Capacity(Gallons) 2 7 4.Material of Construction' Steel (Mark one®) Concrete 0 0 0 0 0 Fiberglass Reinforced Plastic Unknown Other,Please Specify 5.Internal Protection O O O (Mark all that apply-®) Cathodic Protection Interior Lining(e.g.,epoxy resins) 0 None Unknown Other,Please Specify 6.External Protection Cathodic Protection 0 0 (11.1ark all that apply m) Painted(e.g.,asphaltic) ® 0 0 0 Fiberglass Reinforced Plastic Coated 0 0 None 0 Unknowns =a 0 0 O Other,Please Specify 7.Piping Bare Steel o 0 0 0 O (Mark all that apply m) Galvanized Steel © 0 Fiberglass Reinforced Plastic Cathodically Protected 0 0 0 0 Unknown © 0 Other,Please Specify 8.Substance Currently or Last Stored a. Empty 0 in Greatest Quantity by Volume b. Petroleum (Mark all that apply m) Diesel 0 0 0 #2.fie,,1 Kerosene ] 0 0 Gasoline(including alcohol blends) 0 0 Used Oil O O O 0 Other,Please Specify ' c. Hazardous Substance 0 0 0 0 Please Indicate Name of Principal CERCLA Substance OR Chemical Abstract Service(CAS)No. Mark box 13 if tank stores a mixture of substances d. Unknown 9.Additional Information(for tanks permanently taken out of service) a. Estimated date last used (mo/yr) b. Estimated quantity of substance remaining (gal.) c. Mark box 13 if tank was filled with inert material (e.g.,sand,concrete) 0 Page 2 r DEPARTtvIENT OF PUBLIC SAFETY—DIVISION OF FIRE PREVENTION APPLICATION FOR PERMIT TO MAINTAIN AN EXISTING/NEW UNDERGROUND -�- F STORAGE FACILITY To: Head of Fire Department city or Town Date y Form F.P. 290 Application is hereby made for a permit to maintain an existing'/new YQrt4 underground storage facility as required by 527CMR9.00: Permits. Location of property: , S eet av:A-t-'l, Owner of property: /jeL,4C<. Full ame of person, firm or por do ` Signature of owner or authorize representative. /f-�icA �.If Fee:$ (M.G.L.A. Chapt. 148 Sec. 10A) (Fire Department 's Copy to be Filed with F.P.290 part 2) i DEPARTMENT OF PUBLIC SAFETY—D[VI IOtsl 1 OF FIRE PREVENTION . Ez ? M 0 G —Z 19Sly Date Form F.P. 290 TO MAINTAIN AN EXISTING/NEW UNDERGROUND STORAGE FACILITY Part 4 In accordance with the provisions of 527CMR9.24 this permit to maintain an existing/new underground storage facility is granted to: Location of property: 151 S eet addr Owner of property: 11 name of p sop ' or corpor ion Restrictions: Z dU Fee Paid:$ (M.G.L.A. Chapt. 148 Sec. 0 ) This permit will expire a,..� gesignee Date tgn , re of Head of Fire Dept. or appo d (Owner's Copy to be posted at the"storage facility with F.P.290 Part 3) s � 1 Y �F f � i I f E �z q � ry t 1" -3 J kEt 4 L A w _h g, 3 x f } Vy1 7 crr .. J , f :.. � �..- 1 Y �� J j tl iLT. tar? q$ ` �. x1l //��/// �'.!�(