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HomeMy WebLinkAboutNotification for Storage Tanks Regulated Under 527 CMR 9.00 - Correspondence - 1 MASSACHUSETTS AVENUE 11/21/1997 � Ipa�»r��za7zcuecr,�!f o��l�c�a:rac�aeet�"t - �eiaxf�rei�:.to�v�rixa��xvccea X,cutrue &11cco 11'—'PaGlic � �° ,Jeeulcr!ax�" cp�yilca�zceitiG` Notification for Storage Tanks Regulated Under 527 CMR 9.00 Forward completed form, signed by local fire department, to: Mass, UST Program,Dept. 7Date 1101, 111. of Fire Services, One Ashburton Place-Room 1810,Boston, MA 02108-1618 Use Form FP-29OR to notify of tank removals or closures in place, Received:Telephone (617) 727-8500 ept. ID# n (Fire Department retains one copy of FP-290) Fire Dept. Sig. +� O A. New Facility(see instructions,#1) ❑ B. Amended W C. Renewal INSTRUCTIONS! Form FP-290(Notification for Aboveground an -I State Use Only d Underground Storage Tanks)Is to be completed for ouch location containing underground or aboveground storage tanks regulated under 527 CMR 9.00. If more than live tanks are owned at this location,photocopy the following pages and staple continuation shoals to the form. The FP-290 must be A. Facility Number completed In duplicate. Although Ilm form may be photocopied,the facility owner or owner's representative must sign each copy separately;photocopied signatures ate not suft€ctant. 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 forme. The fire department will retain one copy of the FP- 290 for Its records,and the faclfity owner shall be responsible for forwarding the other copy to the DepL of Fire C. Clerk's Initials Services at the address above. The focal lira department will Issue the permit portion of the FP-290;however,registrallon Is not complete until the FP-290 Is received and chocked by the UST Regulatory Compliance Unit. All questions on this form D. Comments are to be answered.Incomplete forms will be returned. VNew Facility'moans a tank or tanks located at a site where tanks have not been previously located. 2'Facillty 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 Ind€care distance and direction from closest Intersection,e.g., (facility at 199 North Street Is located)g-QQ ya (Intersection). IkPORMATION Notification Required Excepllm-(a)a farm orresldentlal tank of 1,100gallonsorless capacltyused for storing motor Fire Prevention Form FP-290 Is to be used as Notification,Registration,and Parmilfor fuel tot noncommoreiaipufposes,or(b)a tank used for storing heating oilforconsumpllve aboveground and underground storage tanks and lank facilities regulated under$27 use on the premises where stored arenotrequired lobo registered under527CMR 9.00. Coda of Massachusetts Regulations 9.00.No regulated aboveground or underground storage tank facility shall be Installed,maintained,replaced.substantially modified or Penalties;Any owner who knowingly falls to notilyor submits false Information shall bosubject removed without a permit(FP-290)Issued by the head of the local Ilia department, to a clvll penalty not to exceed$25.000 for each tank for which notification Is not given or for The owner of any storage facility shall within seven working days notify the head of the which false Information Is submitted.(MGL Choplor 148,section'30H,527 CMR 9.00) local fire department and the Dept.of Fire Services of any change In the name, Aboveground Storage Tanks address,or telephone number of the owner or operator of a storage lacility sublocl to 527 CMR 9.00 requires the registration of any aboveground slorago lank which meets the regulation by Chapter 148,Mass.General law and by 527 CMR 9.00, following definition:a horizontal or vertical tank,equal to or less than 10,000 gallons Underground Storage Tanks capacity,that Is Intended for fixed Installation without back fill above or below grads,and Is Each owner of an underground tank first put Into operation on or after Jan.1,1991, used for the storage of Hazardous Substances,Hazardous Wastes,or Flammable or shall,within thirty days after the lank Is first pill Into operation,notify the Department of Combustible Liquids. Fire Services(the department)of the existence of such tank,specifying,to the extent Ex QpilonRl:Abovegroundtenksofmorethan 10,000 gallons capacity regulated by 520CMR known,the owner of the lank,dale of Installation, capacity,type,focatlon,and uses of 12.00(Requirements lot the Installation of Tanks Containing Flulds Other Than Water In such lank.By no later than Jan.31,1991,each owner of an underground storage tank Excess of 10,000 Gallons)are not required to be registered under 527 CMR 9.00. that was in operation at any time after Jan.1,1974. regardless of whether or not such lank was removed from beneath the 5utface of the ground at any time,shall notify the Exuo0a dZ(a)a farm or residential lank of 1,100 gallons of loss capacly used for storing department of the existence of such tank,specifying,to the extent known,the owner of motor fuel for noncommercial purposes, or (b) a lank used rot storing heating oil for the tank,dale of Installation,capacity,type,and location of the lank,and the type and consumptive use on the promises where stored are not required to be registered under 527 quantity of substances stored In such lank,or which were stored In such lank before CMR 9.00. the tank ceased being In operation If the tank was removed from beneath the surface putties:Anyparson who knowingly violates any rule or regulation mode by the Board of Fite of the ground prior to the submittal of such notice to the department.Such notice shall Prevention Regulations shall,except as otherwise provided,be punished by a fine of not less also specify,to the extent known,the data the lank was removed from beneath the than one hundred dollars nor more[hen one thousand dollars. (MGL,Chapter 148,section surface of the ground prior to the submittal of such notice to the department.The 106,and 527 CMR 9.00) operator of any tank that has no owner or whose owner cannot be definitely ascertained,shall notify the deparlmenl of the existence of such lank,specifying,to the Where to Notify?Two completed notification forms should be signed by both the lank owner extent known,any Information relating to ownership of the lank,and dale of and ilia local fire department.One copy will be retained by the fire department,and the lank Installation,capacity,type,and location of the tank,and the typo and quantity of owner shall send a separate copy to the address a[the lop of this page. substances stored in such lank,or which were stored In such tank before the lank When to Notify?I.Owners of storage tanks In use or that have been taken out of operation ceased being In operation it the lank was removed from beneath the surface of the must notify within thirty days. ground pilot to the submittal Of such notice to the department.If the tank was abandoned beneath the surface of the ground prior to the submittal of such notice to Owners and Operators of Regulated Storage Tank Systems must maintain records Ilia department,such notice shall also specify,10 the extent known to the owner or cortbfying ttet at teak detection,Inventory control and lightness testing requirements operator,the dale the tank was abandoned In the ground and all methods used to for the Regulated Storage Tank System are current.Those records must be readily stabilize the lank after the lank ceased being in operation, available for Inspection, I. OWNERSHIP OF TANK(S) H. 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.85,24, 17W Latitude Longilude P 1 V 13A f f'1t 1 -Q ( I �jyST.....- w /o r W, a ems, ' L it 11 s� sF /lT. 7{RS aµrl N�,J if Sleeer Address Distance en direction +orrt c osesl intersectoQn see instructions 021 � ) Jafl�v3 � o merriMjA4 Facility Name or Company Site tdeatiller, applicable fi �!_ ...C� M/� U(dr r{s a ri G li t.1 o fit : Z`rry lat Z'p� — Slreel Address(P.O.Box not eccapleble-ese Inatructlora 02) 13 .31 i- yt r DPI' al,p�S ounnly�F City Stale ZIP Code Pho a f1h um�rInclude Area ode) vOwnes Employee Federall1 Id 1 Countyr,f FP-290(revised 11/96) 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. (KPrivate ❑ 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 Utilities Airport Federal- Military Residential Aircraft Owner Industrial Farm Vehicle Dealership Contractor Other(explain) VI. CONTACT PERSON IN CHARGE OF TANKS Name:W 1 j f 1,A w` �r� P v1__— Address: Phone Number(include area code): 1 Job Title: 3 MQ3sa( ')e f fit L e Home; 7E-. 0-03`f �r��i`c!B�u�., h A tA W Cvfl/ 0 p S Business: 7 7 - G S 313 VII. FINANCIAL RESPONSIBILITY ❑ 1 have met the financial responsibility requirements In accordance with 527 CMR 9.00. —^ Check all that apply: ._...__._...._,—- i .__...——.__...__ ——._ ——— _—._.—.._ ——._._..�—.. —— pp Y� � � ❑ Self Insurance ❑ Guarantee ❑ Letter of Credit LK Commercial Insurance ( ❑ Surety Bond ❑ Trust Fund ❑ Risk Retention Group ❑ State Fund ❑ Other Method Allowed -Specify 1 1 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 CJ Yes XNo © Unknown 2.Tank site located in surface drinking water supply protection area ©Yes €k%o © Unknown 3, Tank site located within 100 feet of a wetland © Yes A No CJ Unknown 4. Tank site located within 300 feet of a stream or water body WYes ❑ No © Unknown IX. DESCRIPTION OF STORAGE TANKS AND PIPING (COMPLETE FOR EACH TANK AT THIS LOCATION) Tank Identification Number Tank No.j_ Tank No. X Tank No.3 Tank No. q Tank No..s 1. Tank status a. Tank mfr's serial 0 (if known) b. Currently in Use � �--- �- c. Temporarily Out of Use (Start Date) µ tt d. Permanently Out of Use I .J t_---_.J � - e. Aboveground storage lank (AST) or © AST OUST ❑AST KUST Cl AST DUST D-AST q(UST ©AST UST Underground storage tank (UST) 2. Date of Installation (mo.ldaylyr.) ?U l R t, T(, t T 41 3. Estimated Total Capacity (gallons) p C,p o' ecv ao c(/t7 ad o0 Pige 2 FP-290(ravlSfld t{!9G} lrl t/ A T Ill. TYPE OF OWNER ! IV. INDIAN LANDS ;lFederai Government ❑ Commercial 0 Tanks are located on land within an Indian Reservation or on ❑ State Government (storage and sale) other trust lands. ❑ Local Government ❑ Private(storage and use) ❑ Tanks are owned by native American nation, tribe, or individual. V. TYPE OF FACILITY Select the Appropriate Facility Description: (check all that apply) Gas Station Marina Trucking/Transport Petroleum Distributor Railroad Utilities Airport Federal- Military Residential Aircraft Owner Industrial Farm Vehicle Dealership Contractor Other(explain) VI. CONTACT PERSON IN CHARGE OF TANKS Name: Address: Phone Number(include area code); Job Title: Home: Business: VII. FINANCIAL RESPONSIBILITY ❑ I have met the financial responsibility requirements In accordance with 527 CMR 9.00. Checkailthatapply. �.----..-.- __...,._.—..._._--,....._—_.....—..,.. — — �.—__....—......_--_..._ ❑ Self Insurance ❑ Guarantee ❑ Letter of Credit ❑ Commercial Insurance ❑ Surety Bond ❑ Trust Fund ❑ Risk Retention Group ❑ State Fund ❑ Other Method Allowed -Specify 1 1 j VIII. ENVIRONMENTAL SITE INFORMATION ; 3 This information should be available from local health agent, conservation commission, or planning department. i i. Tank site located in wellhead protection area D Yes o No © Unknown s 2. Tank site located in surface drinking water supply protection area o Yes 0 No Q Unknown i 3. Tank site located within 100 feet of a wetland ❑Yes ❑No © Unknown is 4. Tank site located within 300 feet of a stream or water body o Yes © No O Unknown IX. DESCRIPTION OF STORAGE TANKS AND PIPING (COMPLETE FOR EACH TANK AT THIS LOCATION) Yank identification Number Tank No. (o Tank No. Tank No. Tank No. Tank No. 1. Tank status a. Tank mfr's serial tt (if known) b. Currently in Use f c. Temporarily Out of Use (Start ©ate) d. Permanently Out of Use e. Aboveground storage tank(AST) or ©AST UST CAST D UST ❑AST ❑ UST O-AST OUST p AST OUST Underground storage tank (U5T) 2. Dale of Installation (mo.lday/yr.) 3. Estimated Total Capacity (gallons) 6 Cy 0 '•294(revlsod }1l�Jfi} o^^w� lrtntification Number (cont.) Tank No.�_ Tank No._J__ Tank No.z� Tank No._'L Tank No._.S.— "ubstance Currently or Last Stored a. Gasoline F 0 F MV FJ Marina. D MV El Marina 0 MV 0 Marina ❑ MV C€Marina ❑ MV ❑Marina Motor vehicle or other use ❑other o other ❑other ❑other ❑other b, Diesel Motor vehicle or other use MV Cl Marina ❑ MV ❑ Marina ❑MV ❑ Marina El MV ❑ Martha O MV ❑Marina l ❑other ❑ other ❑other Cl other Ll other c. Kerosene d. Fuel Oil "Consumptive Use"tanks need not 6e registered,, "Consumptive Use"fuel used exclusively for area heating and/or hot water. e. Waste Oil f. Other, Please specify Hazardous Substance (other than 4a lhru 4e above) CERCLA name and/or _ CAS number ---------------- ---- Mixture of Substances Please specify 5. Material of Construction-Tank(mark only one) Bare steel (includes asphalt, galvanized and epoxy coated) Cathodically protected steel 0 l Composite (steel with fiberglass) ! Fiberglass reinforced plastic (FRP) � 7— € Concrete Unknown -� — — 3 P: is Other lPlease specify _ 6. Type of Construction-Tank (mark only one) Single walled Double walled 0 �] Unknown [ i [� [ I 0 Other E Please specify I Is tank lined? XYes © Na t('es O-No PkYes ❑No P(Yes ❑ No .tV Yes ❑ No Does tank have excavation'liner7 ❑ Yes ❑No ❑ as ❑ No ©Yes ❑ No ❑Yes 0 No ❑Yes ❑No '-290(revised 1 1196) Pago 3 Tank Identification Number (cont.) Tank No__ _ Tank No. d- Tank No. Tank No._c4__ Tank No..;, 7. Material of Construction-Piping(mark only one) Bare steel (includes asphalt, galvanized and epoxy coated) E:= E= J Cathodically protected steel 1.���J11-� Fiberglass reinforced plastic (FRP) �,,_] tr_—=—.= �-- -� Flexible ❑❑ � Copper Unknown L= E= E7= Other ❑❑ = E= ❑... Please specify 8. Type of Construction-Piping(mark only one) E= ❑ �• Single walled E== c —�t r- 1 ( � �t Double walled E_�.= I_. .._� � t—•-•--� u Unknown C.�,m❑ -�❑ ❑-❑ ❑� �� � � Other a t� �--a � ru E= Please specify Has piping been repaired? 0 Yes ❑ No ©Yes 0 No ©Yes © No ❑ Yes ❑ No 0 Yes ❑ No Is piping gravity feed? ❑Yes 0 No ❑Yes ❑ No Dyes ❑ No 0 Yes ❑ No ❑Yes ❑ No Date X. CERTIFICATION OF COMPLIANCE j 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 ❑J—❑ t� E= E a engineer r-� 1 pP X X D, Installation inspected and approved b y X I—� q 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 El ❑❑ El ❑ B. Approved in-tank monitor X❑ a EX] a a C.Soil vapor monitoring (check one below) ❑ ❑ ❑ ❑ ❑ © Monthly © Continuous E. Inventory record-keeping and tank testing El ❑ ❑ ❑ F. Other method allowed by 527 CMR 9.00. Please specify Page 4 FP•290(tevised 11/96) Identification Number (cont.) Tank No. Tank No. Tank No. Tank No. Tank No. A Substance Currently or Last Stored a. Gasoline (3 MV r]Marina ❑ MV ❑ Marina © MV n Marina o MV C:)Marina O MV ©Marina Motor vehicle or other use o other ❑other ©other o other 0 other b. Diesel Motor vehicle or other use ❑ MV O Marina El MV ©Marina 0 MV ❑Marina o MV o Marina ©MV 0 Marina ©other 0 other 0 other O other ©other c. Kerosene U d. Fuel Oil' consumptive Use"ranks need not be registered. Consumptive Use'fuel used exclusively for area heating and/or trot water. r�•�I� e. Waste Oil f. Other, Please specify Hazardous Substance —� (other than 4a thru 4e above) CBRCIA name and/or CAS number r Mixture of Substances [� l Please specify 5. Material of Construction-Tank(mark only one) Bare steel (includes vanized and epoxy coated) Cathodically protected steel Composite (steel with fiberglass) E 71 Fiberglass reinforced plastic (FRP) Concrete Unknown Other Please specify 6. Type of Construction-Tank (mark only one) Single waited -- Double walled �— Unknown Other Please specify Is tank i1ned7 Yes i� Na ❑Yes ©'No ❑Yes © No ©Yes ❑ No 0 Yes © No Does tank have excavation'liner? 0 Yes ONO �Yes o No ❑Yes © Na �Yes ©No ©Y©s � No Page 3 Cchli� Nvh�� oN f� � r�T Tank Idpntification Number (cant.) Tank No. p Tank No. Tank No. Tank No. Tank No, 7: Material of Construction-Piping(mark only one) Bare steel (includes asphalt, galvanized ❑❑ �] l __-___i and epoxy coated) Cathodically protected steel ?C� r� ❑i r��1 Fiberglass reinforced plastic (FRP) �� a t ---� Flexible = Copper ❑� �Q--�1 �� Unknown ❑ Other u ] E= E Please specify 8. Type of Construction-Piping(marts only one) E= Single walled C Double walled Unknown ---.. Other E= F Please specify Has piping been repaired? 0 Yes 0 No ❑ Yes ❑ No ©Yes © No ❑ Yes ❑ No O Yes ❑ No Is piping gravity feed? ❑Yes © No © Yes ❑ No ©Yes ❑ No 0 Yes © No ❑Yes ❑No Date 't X. CERTIFICATION OF COMPLIANCE li 1. Installation � -❑ A. Installer certified by lank and piping manufacturers B. Installer certified or licensed by the �❑ L� L___ _^1 Implementing agency C. Installation inspected by a registered ^❑ t___� engineer D. Installation inspected and approved by the Implementing agency � —t r��-t E. Manufacturers r installation checklists E= t E, have been completed F. Another method allowed by 527 CMR 9.00. Please specify 2.Tank teak Detection Tank Tank Tank Tank Tank (mark only one) A. double-wall tank - Interstitial monitoring ❑ ❑ ❑ ❑ B. Approved In-lank monitor ❑ ❑ ❑ ❑ ❑ C.Soil vapor monitoring (check one below) ❑ ❑ ❑ Eloo ❑ ❑ Monthly ❑ Continuous 01 E, Inventory record-keeping and lank testing ❑ ❑ ❑ ❑ ❑ F. Other method allowed by 527 CMR 9,00. Please specify µ_ ._ 0w A Tank No. � Tank No. Tank No. S Tank Identification Number (cont.) Tank No.❑_ Tank No. _ Piping 3. Piping Leak Detection (mark only one) Piping Piping Piping Piping P 9 A.Pressurized ❑❑ ❑ El ❑ a. Interstitial space monitor ❑ ❑ ❑❑ b. Product line leak detector (mark all that apply below) ❑ Automatic flow restrictor' ❑ Automatic shut-off device- ❑ 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 ❑ ❑❑ ❑❑ ❑ ❑ (Requires interstitial space monitor or line tightness test every three years) CI Interstitial space monitor ❑ Line tightness test C. Suction: Check valve at dispenser only a a (No monitor required) D. Other method allowed by 527 CMR 9.00. Please specify — � 4. Date of last tightness lest (tank & piping) to r 5. Gravity feed piping ❑ ❑ ❑ ❑ ❑ ' Tank Tank Tank Tank Tank l 6. Spill containment and overfill protection A.Spill containment device installed X B.Overfill prevention device installed �C❑ ❑❑x Z ❑ I 7. Daily Inventory Control (mark only one) A. Manual gauging by stick and records ❑❑ ❑❑ C❑ ❑ ❑❑ reconciliation El ❑ ❑ ❑❑ B. Mechanical tank gauge and records ❑❑ reconciliation 0 a C. Automatic gauging system �U4e �c Tank Piping Tank Piping Tank Piping Tank Piping Tank Piping 8. Cathodic Protection (if applicable) ❑❑ ❑ ❑❑ ❑❑ ❑❑ �❑ ❑1 ❑❑ ❑❑ ❑❑ A. Sacrificial Anode Type ❑❑ ❑ � � ❑�} © � ❑�❑ © ❑�❑ B. Impressed Current Type C. Date of Last Test � � 7 Certification of Compliance No.: X1. CERTIFICATION (Road and sign alter completing all sections) ned separately. A phniocopled stgnalura will not be NOTE:Both the copy being sent to the Dept.of Fire Services and the copy retained by the local fire department must be sig accepted on nithor document. arid I declare under penalty of perlury immediately I have P0 responsible for obtaining the nfomsatlolne I believe That the submittedf with the Information Information!stted In this lruta,alccurateached aand complete. that based on my Inquiry of those Date: Name and ciflclal title of owner or owner s authorized represenlalfve(Print) Signature,. r+ Page re_r)en hauisnd I tl961 Tank No.� Tank No. Tank No. Tank No. Yank No. ,yank°Identification Number {cent.} Piping piping Piping Piping Piping 3. Piping leak Detection (mark only one) ❑ A.Pressurized ❑ ❑ El a, Interstitial space monitor �--} ❑ ❑ ❑ b. Product line leak detector ❑ LJ (mark ail that apply below) 0 Automatic Ilow restrictor' ❑ Automatic shut-off device` 1p 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 ❑ ❑ (Requires interstitial space monitor or line tightness lest every three years) ❑ interstitial space monitor ❑ Line tightness lest set only ❑ Eli ❑ C. Suction: Check valve at dispen [� (No monitor requiredr D. Other method allowed by 527 CMR --- ------- 9.00. Please specify 4, ©ate of last tightness test (tank& piping) f! � �� -�—•------ '�"� El 5.Gravity feed piping Tank Tank Tank Tank Tank 6. Spill containment and overfill protection ❑ ❑ A. Spill containment device installed El ❑ ❑ ❑ B.Overfill prevention device installed 7. Daily inventory Control (mark only one) . stick and records ❑ ❑ A. Manual gauging by ❑ El Elreconciliation ❑ ElElB. Mechanical tank gauge and records ❑ ❑ reconciliation ❑ EJ C. Automatic gauging system Tank Piping Tank Piping Tank Piping Tank Piping Yank Piping S. Cathodic Protection (it applicable) El El �} ❑ El ❑ ❑ ❑ L_1 i�t ❑ a ❑ �1 A. Saeritieiai Anode Type ❑❑ r--� �} I❑ ❑ � � 13. impressed Curren(Type -- C. Date of Last Test 7 ~ Certification at Compliance No.: X1. CERTIIFICATION (Tie ad and sign alter completing all sections) afa161 A nIs ot000pted siynelure w111 not ba retained by the local W.department must be alpned sop Y• faOTs:Both ilia copy being sent to the Dept.ai Fire sorvicas and the copy accepind on either document. tale. u that ocumen I have personally examined and am familiar bolSevoothat the submittediInformation is lWa attached ea and comp and that basedon my I dectare under penalty of pail ry inquiry of those Individuals tmmndlatoly responsible for laintng the Print) Si nature: } r lot Name and ollictal Milo of owner or ovrner's authorized Ic rgsanlalive(Print) g /t' f]_' _ Pa /0 iGU))t.I;1a)r•[u f(czj;trzc ctje(ri, , ;r,�4Lg ( ��-cc�:�y�ac��cl'a��✓ ic��r; tyre f - "(i' LC� af�l�iF, C%lcrleJ'�tU APPLICATION roll PC-11MiT TO P ahitain an Existing/New Storage Taiik Facility Regulated miler 527 GIV1t3 9.00 t To: head of Fire Depar ill ront City, to,.vn or district: n llcS v dale: lilt.vl9 r'.1 Vlicalion is [iereby mado for a permit to maintain an oxislinq/} aw storage tank facility as required by 527 CtAFt 9,00; -ocallon of property: ».gc1s-s_e —fj ALe c,v e. Slreef address ;V/ner of property. �...�A Foil nurtra nl poison.lion or cmparakurr qui-riber cf stcrage tanks: „_.Q aboveground undcrcdrnurrd Signature of owner or authorizod representative: =eft paid:.$ 25' 00 00-G.L, Chapter 140, section 10A) (Fire 0eparl/110111'S copy- To Uo filed rvittl rp-230, tart l) r _.. .._.— .__ .-...———__.. ..,_ —..... _ � /C; 1 '0))1-V)t(-w11C1C[Gl/r/ O�t?-'!'LG�1r1CtC/LCI,J�t�y � ,•U''f' �C�!{(, �,)l.r'I'l r E�' �cGt D cJ('f l�lf. - rCr 1 C6 O/'Lie '>C:1re SJ CCG7Ij/m!l 'I O PERMIT To Maiilltilin att Existi119/New Stange Tank Facility fcrr Stc,racfe 'yanks Regulated udder 527 CM1� 9.00 i accordance willi the provisions of 527 CMR 9.00 thls permit to maintain all existing/new slorage tank facility r grailled to: i jot:ation of propefly: 3 Massachusetts Avenue Saver address -�- f I y" „ lty-Trust �vner o �rcti Berl ..`.. _._ PAtob Rea,.. _ �.____ ._.....____.._. .._ Full uenrrl of pawn,rirm or curpo(,tf+un i rllnber of storage tanks: 1 aboveground 6 underground , H , >trr,ility l0 1)0 rnai"Wined in accordance Willi the restrictions described belo�: ; MUST MAINTAIN COMPLIANCE WITH M.G.L. CHAPTER 148 SECTIONS 9, 10A 3 a n r3 5 27 5 �_.8 r 9—,and 10 WHERE. APPLICABLE 1 'Q Laid' S (M G.L. (:1t��F�ter f�113, serriarf 10A) I lis pernil will ex giro � /x__� C -� bare S.-37nalure of f fead of Fire 0oparfnrom or apl+or.�r�a desr�^�e r _ ^' (O;vilor's copy- To be posted al the slorage laeifiry)