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Home My WebLink AboutApplication for Permit to Maintain an Existing/New Underground Storage Facility - Permits - 1 MASSACHUSETTS AVENUE 8/1/1991 16) , , �L\ The Commonwealth of Massachusetts Department of Public Safety Division of Fire Prevention and Regulation APPLICATION FOR PERMIT TO MAINTAIN AN EXISTINGMEW UNDERGROUND STORAGE FACILITY TO: Head of Fire Department _North _Andover August 1 19 91 City, Town or District Date Application is hereby made for a permit to maintain an existing/new underground storage facility as required by 527 CIMR 9.00: Permits. Location of property: 1 - 3 Massachusetts Avenue Street Address Owner of property: Patob Realty Trust Full name of person, firm or corporation Signature of owner or authorized representative: ( FEE: $ ] 0_oo (M.G.L.A. Chapt. 148 Sec. 10A) FORIA F.P.290 (Fire department's copy to be filed with F.P. 290 Part 2) (rev, 10/90) 3 The Commonwealth of Massachusetts Department of Public Safety E Division of Fire Prevention and Regulation PERMIT [ August 1 19 91 Date TO MAINTAIN AN EXISTING/NEW UNDERGROUND STORAGE FACILITY in accordance with the provisions of 527 CMR 9.26 this permit to maintain an existing/new underground storage facility is granted to: Location of property: 1-3 Massachusetts Avenue Street address Owner of property: Patob Realty Trust Full name of person. firm or corporation Restrictions: MUST BE RENEWED ANNUALLY Fee Paid:$ 10 .00 (M.G.L.A. Chapt. 148 Sec. 10A) This permit will expire � 19 pa;p ipnelufa of Head of Fire Dept. or appointed dealynee FOW F.P.290 (f°"' 1Q1go) � (Owner's copy to be posted at the storage facility) i Department of Public Safety 4: 2Division of Fire Prevention and Re ulation STATE USE ONLY Notification for Underground Storage Tanks ID NUMBER FIRE DIPT. O R U Submit t0: DATE RECEIVED LOCAL FIRE DEPARTMENT A, Date Entered Into Computer �- B.AMENDED ❑C.CLOSURE B. Data Entry Clark initials A.NEW FACILITY , 0 _ — �ly,No,of tanks at facility — No,a1 continuation sheets attached G. Owner Was Contacted Comments INSTRUCTIONS Please tvs^'_e __oriQLtEt1111iall items except"signature'in section V.This form must be completed for each location containing underground sto of#owing H more than five(5)tanks are owned at this location,photocopy sheets, and staple continuation sheets to the form, 7.septic tanks; adterin9 lines}regulated under the Natural Gas Notification to required by Federal law fa all underground ts1984 that hat 6.pipeline facilities(including g have been used to store regulated substances since January 1, Pipeline Safety Act of 1968,or the Hazardous Liquid Pipeline watery Act of 1979,or are In the Around a■of May 8,1996,or that are brought into use attar May B, which is an intrastate pipeline Facility regulated under tavrs; required by Section 9002 of the nasouroa 6,surface impoundments,pits,ponds, stems; '.; 1986,The Information requested RCA),as amended. 6,Storm water a waste water collection sy Conservation and Recovery Act,( T,1ko 1-through process tanks; of this notification program is to lopre and evaluate gathering lines directly related to oil or gas The pnr^ary purposetroleum or hazardous substances. S.liquid trap a hessi soaateatns-, underground tanks thaf- at store w have stored petroleum production and gathering opal h is expected that the infn or ormation you provide will be based belief,or .storage tanks situated rnl the storage tank s situate upon or above available records.or in the absence of such records,ymineworking,drift,shah, ) recollection. cites that,unless surface of the floor, under Who Must Notify?Section 9002 0l RCRA,as amended•requires What Substances Are Covered?The notification requirements app y tanks that contain regulated substances.This includes any exempted,owners of underground tanks that store regulated substances must deiir€ta hazardous In��101(14)of the Comprehensive exempted, designated State a local agendas of the existence o1 their tanks.Owner ground compensation and Liability Act oI 198o(CERCLA),with nol4�� Environments!Response,Cornpe a)In the ease of an underground storage tank in use on November 8,1984,or the exception of those substances regulated as hazardous waste under Subtitle C C troleum,e.g.,crude ail or any hacrion thereof which is brought inro use after that date,any person who owns an underground storage RCRA,1t also Includes Pe degrees Fahrenheit tank used for the storage,use,or dispensing of regulated substances,and liquid at standard conditions of temperature and pressure(60 round store tank in use before Novembar 8, and 14.7 pounds per square inch absolute). b)in the Case or any underground 9a 1984.4ut no.longer is use On that date,any perstxtwho owned such tank Where To NOW)? ('umpletcd nr�titiceli,m t.1rin+�hrtuld be vnI t,�the adttn•. immediately before the discontinuation of its use. gncn at thr top of thl+page ires,any facility that has undergone any changes to facility Information or tank system status(only ame rxied tank information needs c)it the State agency so requ to be included). What Tanks Are Included?Underground storage tank is defined as any the When To Notify?i.Owners of underground 4storage t still sin the ground,mustave or Combination of tanks that(1)is used to can[a n an accumulaton of'reguia€ed been taken out of Operation after January round piping)is May 8 t986 2 rarrners who bring underground storage tanks into use alter i✓K substances,*and(2)whose volume(irtdudinq connected underground within 30 days of bringing the tanks into use• tubs a more beneath the ground.Some examples are underground pesticides, storing: 19M.must nosy 1.Gasoline,used oil,or diesel fuel,and 2.industrial solvents, herbicides of fumigants. What Tanks Are Excluded?Tanks removed from fhe ground are not subject pan&Rlss:Any owner who knowingly tails to notlty or submits false to notification.other tanks excluded from notification are: 1.term or residential tanks of 1,100 gallons or lass Capacity used for storing ink forInformatwhleh ion notification Is ncA given orfor which fal�nformattion laeacF motor fuel for noncomrrefdal purposes; remises submitted. Itanks used for storing heating oil for consumptive use on tfte p where stored; 11, LOCATION OF TANK(S) 1.OWNERSHIP OF TANK(S) fees,rrinoug,and seconds. V raqured by Stare,Aka the g soa 85.24,17w {ocxtlon or Wks by deg re". ies I.at.42. .f2 N Long•a5.2 owner ,,,{ soon,kWNidi,al.Public Agency.or carer Enrh) Latitude Longitude-----Address fd same as se W 1,maA box here n) V L' _ -- .._---• ex.wnrMisr_a arnliCabla vr' 1Afly (]:1- (A.) My (,, l_ i N 0P'I'I I 0hli:)C)tJl._I MA i_)1. '3/j.':i ISM F.P.290 (rev. 10190) I !^^ DESCRIPTION OF UNDERGROUND STORAGE."TANKS(Complete far each tank at this location.) ------ IX. 3 Tank No. Tank No•a Tank No._4,. Tank No.;I-- Tank No. } Tank identification Number E�C___J -- L._..-- 1.Status of Tank Currently in Use (��`��} L.__—.—•---' � �,��—I (mark only one) Temporarily Out of Use Permanently Out of Use L -- (MMIn6w bf aA►K~Ix Amendment of information 2. Date of installation (mo./year) � �� c � Capacity(gallons) 0 ti C U 0 00 ; 3.Estimated Total Capa Y(t3 } 4.Material of Construction (Mark all that apply) Asphalt Coated or Bare Steel Cathodically Protected Steel Epoxy Coated Steel Composite(Steel with Fiberglass) Fiberglass Reinforced Plastic Lined interior Double Walled Polyethylene Tank Jacket Concrete Excavation Liner Unknown _�—_-1 .— — _—.�- — — Other,Please specify Has tank been repaired. 5.Piping(Material) Bare Steel --� (Marts all that apply) (�L�.—••-----' Galvanized Steel Fiberglass Reinforced Plastic Copper Cathodically Protected C^ Double Walled `�—.-------- Secondary Containment �l__-------' � L —Y-- Unknown 1�— ----a r Other,Please specify B.Piping(hype) -�- - (Mark all that apply) Suction:no valve at tank Suction:valve at tank Pressure -- Gravity Feed Has piping been repaired? XI. CERTIFICATION OF COMPLIANCE(COMPLETE FOR ALL NEW AND UPGRADED TANKS AT THIS LOCATION) r Tank No. �- Tank No. � Tank No Tank No. Tank Identification Number Tank No. t. Installaiion A. Installer certified by tank and piping manufacturers B. Installer certified or licensed by the E== implementing agency LL'�-------� C. Installation inspected by a � registered engineer D. Installation inspected and (� approved by implementing agency E. Manufacturer's installation check- lists have been completed F. Another method allowed by State L_�.--„—„•—' ._1 agency. Please specHy. 2. Release Detection(Mark all that apply) TANK PIPING TANK PIPING TANK PIPING TANK PIPING, TANK i PIPING A. Manua{tank gauging F—A XrTl iII B. Tank tightness testing x C. Inventory controls D. Automatic tank gauging E. Vapor monitoring F. Groundwater monitoring �1 G.Interstitial monitoring double walled tanWpiping H. Interstitial monitoring/secondary containment I. Automatic line leak detectors J. Line lightness testing -- K. Other method allowed by ----- �—��-� Implementing Agency. Please specify. �'-�--- 3.Spill and Overfill Protection A. Overfill device installed x B. Spill device installed g installation that is provided in section OATH: I certify the information concernin X is true to the best of my belief and knnwiedge. Date Signature Installer: Name company Position r' IX.DESCRIPTION OF UNDERGROUND STORAGE TANKS(Complete for each tank at this location.) Tank.Identification Number Tank No.L Tank No. Tank No. Tank No. Tank No. ' 1.Status of Tank �� (mark only one) Currently in Use L_..�-..!> —— Temporarily Put of Use (RRM Permanently Out of Use E= —� —j — — " rH•�•*o«bIr wlweon lXl E= Amendment of Inlormation 2.Bate of Installation(mo./year) 9 7 3. Estimated Total Capacity(gallons) „'O bp'0 4. Material of Construclion (Mark all that apply) —.....—.�- Asphalt Coated or Bare Steal Cathodlcally Protected Steel I L '2 Epoxy Coated Steel Composite(Steel with Fiberglass) Fiberglass Reinforced Plastic Lined interior I Double Walled Polyethylene Tank)acke ConcreteExcavation Liner Unknown — - - Other, Please spectly I Has tank been repaired? rr -- --- �� 5. Piping(Material) (Mark all that apply) - Bare Steel Galvanized Fiberglass Reinforced Plastic L- -•� �► ... ' Copper! Protected Cathodicall yT fJouUke Walled Secondary Containment Unknown dther, Please specify 8.Piping(Type) (Mark all that apply) (�� Suction:no valve at tank L_ _--^--•� r I Suction;valve at tank E= r---- i pressure, _._` _' Gravity Feed Has p,:)ing„aen repaired? page r7, entification Number Tank No. Tank No. Tank No. Tank No. Tank No, ubstance Currently or Last Stored In Greatest Ouanttly by Volume Gasoline Diesel ��—��" -- r..�---� � r—"' Gasohol L.,..._ .....�- Kerosene. — = Heating OilFEil lased Oil Other, Please specify Hazardous Substance --f` CERCLA name andior, ' �-�--- CAS number r ' Mixture o1 Substances ---� Please specify X.TANKS OUT OF USE OR CHANGE IN SERVICE 1 Closing of Tank A. Esturnated date last used — " (mo.lday/year) r` _—— —_ B. Estimate date tank closed (mo.ldaytyear) 3,_ T C.Tank was removed from ground D. Tank was dosed in ground .-J] �------' E. Tank filled with inert material L—..---J -- --- Describe — --�-- F. Change in service -------� 2. Site Assessment Completed Evidence of a leak detected _ E i f Xi. CERTIFICATION OF COMPLIANCE(COMPLETE FOR ALL NEW AND UPGRADED TANKS AT THIS LOCATION) Tank Identification Number Tank No, Tank No. Tank No. Tank 1N1,3,. Tank No. s 1. Installation _ A. Installer certified by tank and . ��-1 '—•—' piping manufacturers — B, installer certified or licensed by the Implementing agency C. Installation Inspected by a registered engineer D. Installation inspected and approved by implementing agency E. Manufacturer's installation check- lists have been oompleled F. Another method allowed by State agency.Please specify. ' 2.Release Detection(Mark all that apply) TANK l PIPING i TAN K PIPING TANK PIPING` TANK PIPING1 TANK PIPING I 1 ; A. Manual tank gauging B. Tank tightness testing C. Inventory controls D. Automatic tank gauging ! . Vapor monitoring n rJtr. ' F. Groundwater monitoring �'J ' ; - onhorrn b walled G.Interstitial m 9 double tank'piping H. Interstitial monitoringrsecondary t--} �—_J --� containment I. Automatic line leak detectors r — J. Line tightness testing K. Other method allowed by implementing Agency.Please — — specify. ------ - g.Spill and Overfill l'raroclion � A. Overfill device installed B, Spill device installed OATH:!certify the information concerning installation that is provided in section X is true to the best of my beliet and knowledge. Installer: S'sgnatwe Date Name ------ -- _ — Company Pa�c