DFS1FD 02 60 00 UST EXCAVATION AND REMOVAL 072226DR - pdf.pdf

Excavation and Removal of Underground Storage Tank 02 60 00-1

DARTMOUTH FIRE STATION NO. 1

NEW FUEL DEPOT

DARTMOUTH, MASSACHUSETTS 22 JULY 2026

RT ARCHITECTS, INC.

SECTION 02 60 00

EXCAVATION AND REMOVAL OF UNDERGROUND STORAGE TANK

PART 1 - GENERAL

1.1 GENERAL PROVISIONS

A. Attention is directed to the CONTRACT AND GENERAL CONDITIONS and all Sections within DIVISION 01 - GENERAL REQUIREMENTS which are hereby made a part of this Section of the Specifications.

1.2 DESCRIPTION

A. Provide all labor, equipment and materials necessary to demolish, uncover, clean, remove, disconnect, and dispose of the underground storage tank and any associated piping. The tank is a double-walled metal tank with Diesel fuel. Refer to the Tank Detail Report.

B. Remove and dispose of all sludge and solid waste in the Tank. Diesel fuel will be removed by the Owner.

C. Demolish, excavate, stockpile, load, transport, and dispose of contaminated soil (if any). Contaminated soil shall be determined by testing. It is the Contractor’s responsibility to perform cleaning of the area after removal of stock piled soil from the site. The Contractor MUST include in his/her bid the removal and disposal of 50 cubic yard of contaminated soil. Addition will be based on $250.00 per cubic yard and deduction will be based on $220.00 per cubic yard.

D. Protect existing utilities from damage.

E. Arrange and pay for all licenses, permits, inspections, and tests as required.

1.3 EXAMINATION OF SITE AND DOCUMENTS

A. It is hereby understood that the Contractor has carefully examined the site and all conditions affecting work under this

Section. No claim for additional costs will be allowed because of lack of full knowledge of existing conditions.

B. Measurements, and dimensions, under which the work is to be performed are believed to be correct to the best of the

Owner's and Designer's knowledge, but the Contractor shall have examined them for himself during the bidding period, as no allowance will be made for any errors or inaccuracies that may be found herein.

1.4 SUBSURFACE SOIL DATA AND SITE CONDITIONS

A. Soil Data

1. It is the obligation of the Contractor to examine the site, to verify all dimensions in the field, to review any pertinent data available, and to employ all other means at his disposal to familiarize him-self completely with conditions existing at the site. At his own expense, the Contractor may take whatever borings or explorations he deems necessary.

2. It is the Contractor's sole responsibility to make interpretations and draw conclusions with respect to the character of the materials to be encountered and their impact upon his work based on his knowledge of the area and of construction techniques. Neither the Owner nor the Designer assumes any responsibility.

02 60 00-2

DARTMOUTH FIRE STATION NO. 1

NEW FUEL DEPOT

B. Utilities - The Contractor shall visit the premises to familiarize himself thoroughly with all details of the work and of working conditions, to verify all dimensions in the field, and to advise the Engineer of any discrepancy before performing any work. The Contractor shall consult official records of existing utilities, both surface and subsurface, and their connections, and shall fully inform himself of all existing conditions and limitations as they apply to his work and of the extent and character of the work required under this section and its relation to all other construction work.

1.5 PERMITS, CODES, AND SAFETY REGULATIONS

A. All work shall conform to the Specifications and comply with applicable codes and regulations including City of

Cambridge.

B. Comply with rules, regulations, laws, and ordinances of all authorities having jurisdiction, including but not limited to, Massachusetts Department of Environmental Protection (DEP), and the State of Massachusetts. All labor, materials, equipment, and services necessary to make the work comply with such requirements shall be without additional cost to the Owner.

C. Comply with the provisions of the Manual of Accident Prevention in Construction of the Associated General

Contractors of America, Inc., and the requirements of the Occupational Safety and Health Administration, United

States Department of Labor.

D. The Contractor shall procure and pay for all permits and licenses required for the complete work specified herein.

E. The Contractor shall not close or obstruct any street, sidewalk, or passageway. The Contractor shall so conduct his operations as to interfere as little as possible with the use ordinarily made of all roads, driveways, sidewalks, or other facilities near enough the work to be affected thereby. Parking areas shall be limited to those areas so designated by the Owner.

1.6 REFERENCES

A. OSHA Construction and Earthwork Standards.

B. Massachusetts 310 CMR 9.00 - Tank and Containers.

C. Massachusetts 527 CMR 30.00 - Hazardous Waste Regulations.

D. Massachusetts 310 CMR 40.00 - Massachusetts Contingency Plan.

E. Massachusetts DEP Policy #WSC-89-001.

1.7 SUBMITTALS

A. Prior to the start of work, the Contractor shall submit a written work plan, to the Owner or his representative, describing the proposed work schedule/sequence for removal of the Tank, including, but not necessarily limited to, descriptions of steps to be taken for protection of existing utilities, anticipated schedule, the location of the stockpile for any contaminated soils that may be excavated, the end disposal site for any sludge removed from the Tank and the anticipated disposal site for contaminated soils that are encountered.

B. Prior to the start of work, the Contractor shall provide proof that Tank removal permits have been obtained from the local fire department.

02 60 00-3

DARTMOUTH FIRE STATION NO. 1

NEW FUEL DEPOT

C. The Owner will retain the services of a Licensed Site Professional (LSP) to over see the removal process and to collect soil samples for analysis (48-hours results) at no additional cost to the Contractor.

D. Within 24 hours of any off-site disposal of Tank, the Contractor shall provide the Owner with copies of all associated manifests, Bills of Lading and Tank disposal permits. It is the Contractor’s responsibility to obtain the services of a LSP to sign the Bills Of Lading (BOL).

1.8 HEALTH AND SAFETY PLAN

A. Contractor shall maintain a health and safety plan (HASP) in compliance with OSHA standards defined in 29 CFR

1910.120.

B. Contractor’s employees or subcontractor’s employees will be cleaning the UST and or handling petroleum or VOC impacted soil or groundwater shall be required to have OSHA 40-hour health and safety training as required.

1.9 HAZARDOUS WASTE LICENSES

A. Contractor or subcontractor, whichever shall be transporting the waste material from the Tank cleaning, shall have a currently valid hazardous waste transporter license for the Commonwealth of Massachusetts and any other state for which the transporter shall pass on its way to a licensed receiving facility. The contractor shall provide copies of the licenses to the Engineer prior to commencement of the work.

B. Contractor shall provide the Engineer with the name and address of all licensed receiving facilities to be used for this project, one week prior to the commencement of on-site activities or sooner.

PART 2 - PRODUCTS

2.1 EXISTING CONDITIONS

A. Existing tank is 6,000 gallons size. Refer to the attached Tank Detail Report.

B. Protection of Existing Facilities.

1. The Contractor's attention is directed towards the possible existing of electrical conduit.

2. Prior to Excavation, the Contractor shall carefully uncover the existing utilities for inspection by the Owner or his representative. Hand excavation shall be used to the degree necessary to protect the utilities from damage.

3. The Contractor shall take all necessary precautions to protect existing utilities during completion of the work. Any damage caused to the utilities shall be the responsibility of the Contractor and shall be repaired at the Contractor's expense.

4. The Contractor shall take all necessary precautions to protect existing structures from damage during execution of the work. Any damage caused to structures shall be the responsibility of the Contractor and shall be repaired at the Contractor's expense.

2.2 PERMITS AND NOTIFICATIONS

A. The Contractor shall obtain all permits and perform all notifications required to complete the work.

B. The Contractor shall obtain a "Dig safe Number" if needed.

02 60 00-4

DARTMOUTH FIRE STATION NO. 1

NEW FUEL DEPOT

C. Removal of the Tank shall comply with all aspects of 527 CMR 9.00 and the local fire department requirements as summarized below:

1. Forty-eight (48) hours prior to the proposed removal of the Tank, written notice shall be sent to the Local Fire

Department. The notice shall include the following information:

a. The address of the site from which the Tank is to be removed and the name and address of the owner of the property.

b. The name and address of the company, which will remove the Tank.

c. The name and address of the company, which will perform the site survey at the time the Tank, are removed.

d. The name and address of the facility, which will receive the Tank.

2. Within seventy-two (72) hours of the Tank removal off-site, the facility receiving the Tank shall notify the local Fire

Department of its receipt in accordance with 527 CMR 9.10, 9.14, and 9.15.

3. Following the completion of removal of the Tank, a report from the company making a survey of the site shall be sent to the local Fire Department. Such report shall state the condition of the Tank at the time of its removal and the condition of the soil from which the Tank has been removed.

D. If any odor or visual evidence of a leak or underground petroleum is encountered in the Tank hole, all reporting or other actions required by federal, state of local regulations should be identified to the Owner or his representative.

PART 3 - EXECUTION

3.1 REMOVAL OF THE TANK

A. Prior to Excavation, the Contractor shall thoroughly inspect the fuel system to determine that all products has been drained from pipes and removed from the Tank to the maximum degree possible.

B. Prior to removal of the Tank, all pipe lines connected to the Tank shall be fully exposed, purged free of product, and disconnected at both ends. All existing pipes that are cast into or under concrete or cannot be readily removed shall be plugged at both ends with concrete. All other pipes shall be fully removed. All pipes left in place shall be approved by the Owner or his representative prior to plugging.

C. All vent lines attached to the side of buildings shall be carefully removed so as to minimize damage to the walls.

D. Before uncovering, removing, or disconnecting the Tank the contents shall be pumped out as completely as possible by using a suction hose extended to the Tank bottom. All product and sludge shall be removed from the Tank prior to removal of the Tank from the ground. The Contractor shall be responsible for the disposal of all product and sludge removed from the Tank.

E. Following cleaning and before any cutting, the Tank shall be purged free of vapors by adding crushed solid carbon dioxide (dry ice) in the amount of at least 15 pounds per 1000 gallons of Tank capacity, evenly distributed over the

Tank bottom.

F. Remove and properly dispose of the sand between the outer walls and Tank.

G. Cut the Tank into small sections.

02 60 00-5

DARTMOUTH FIRE STATION NO. 1

NEW FUEL DEPOT

H. All removed pipes and Tank shall be purged, cleaned, and rendered gas free for safe, off-site disposal at an approved disposal site.

I. No fire or open flame shall be allowed in the removal area, during the entire Tank removal procedure.

J. No person shall enter the Tank first without testing the Tank for an explosive atmosphere or without the use of self-contained breathing equipment. All other appropriate closed vessel entry procedures shall be followed at all times.

K. The outside of all removed Tank and pipes shall be cleaned of soil/sand and any product, prior to removal from the site.

L. All residual product, sludge and cleaning water shall be containerized for off-site disposal within 24 hours of completion of the Tank removal process.

M. Any product released during removal of the Tank shall be contained and absorbed using pads, booms and speedy dry, as needed. All costs associated with cleaning up the release, which occurred during the removal of the Tank, shall be the responsibility of the Contractor.

N. Power-wash the room upon completion of all work.

3.2 EXPOSING OF SOIL

A. All soils/sand shall be separated into stockpiles of contaminated soils (if any).

B. All contaminated soil/sand shall be stockpiled on sheet polyethylene as directed by the Owner or his representative.

C. The containment dike shall be constructed prior to placement of the polyethylene and polyethylene shall be placed over the top of the dike, extending to the outside edge of the dike.

D. The stockpile of contaminated soil/sand shall be completely covered with sheet polyethylene, which shall then be secured in place so as to eliminate movement.

E. Following exposing of all contaminated soil/sand, the Owner’s LSP will obtain representative samples from the stockpile of contaminated soil/sand. Samples obtained will then be analyzed for determination and approval of final disposal. Analysis methods and frequency of analysis will be performed as follows:

1. Contaminated soil stockpile.

a. Total Petroleum Hydrocarbons (TPH) -1 representative analysis from the stockpile and an additional 1 per each additional 100 cubic yard.

b. Flash point - 1 representative analysis.

c. Polychlorinated Biphenols - 1 representative analysis.

d. E.P. Toxic Metals - 1 representative analysis.

e. Reactivity Sulfide - 1 representative analysis.

f. Reactivity Cyanide - 1 representative analysis.

g. Water Reactivity - 1 representative analysis.

h. PH - 1 representative analysis.

i. Total Lead and Barium - 1 representative analysis.

j. Volatile Organic Compounds - 1 representative analysis and an additional 1 per each additional 100 cubic yard.

2. Appropriate Chain-of-Custody forms will be provided for all samples and resultant analyses.

02 60 00-6

DARTMOUTH FIRE STATION NO. 1

NEW FUEL DEPOT

3. Testing results will be returned to the Contractor or his representative within fourteen (14) calendar days of the stockpile sampling.

4. Soil shall be removed off-site to an approved facility, under proper BOL, within 30 days of stock piling.

END OF SECTION

Tank Detail Report

Status In Use

Owner Tank ID 1/2

Financial Responsibility commerce and industry company

Commercial Insurance (Owner)

Install Date 10/15/1991

Tank Construction Double-walled metal tank (cathodic protection required)

Total Capacity 6,000

Compa�tments

Capacity

4,000

2,000

Piping Install Date

Piping Description

Contents

Diesel

Diesel

Use

Motor Vehicle

Motor Vehicle

10/15/1991

European suction system

CAS Reg.#

Piping and Fittings Construction Material

Turbine Sumps

Is the tank equipped with a submersible pump?

Submersible Pump Installation Date

Single-walled non-corrodible material (No corrosion protection required)

No

Is the tank equipped with a turbine sump? No

If yes, is the turbine sump equipped with a sump sensor No continuously monitored for liquids?

Intermediate Sumps

Is the piping system associated with this tank equipped with No one or more intermediate sumps?

.i yes, is this intermediate sump equipped with a sump No sensor continuously monitored for liquids?

Spill Buckets

Spill Bucket Installation Date

Is the spill bucket equipped with sensors? No

Overfill Prevention Devices

Overfill Prevention Device Installation Date

Primary Overfill Prevention Device Type Automatic shut-off valve

Tank Leak Detection

Leak Detection System Installation Date

Primary Leak Detection System Type Continuous Interstitial Monitoring

Piping Leak Detection

Leak Detection System Installation Date

Leak Detection System Type Quarterly visual inspection and annual product line tightness

Automatic Leak Detection

Leak Detection System Installation Date

Tank Corrosion Prevention System Type

Pipe and Fitting Corrosion Prevention System Type

Manufactured Sacrificial Anode (Galvanic) System

FP-290 (revised 05/08) Page 1

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Notification for Underground Storage Tanks Regulated Under 527 CMR 9.00

Forward completed form to:

Massachusetts UST Program, Dept. of Fire Services, P.O. Box 1025 - State Road, Stow, MA 01775

978-567-3375

Forward one copy of FP-290 to the local fir(! department.

DA. New Facility (see instructions, #1)

INSTRUCTIONS: Form FP-290 (Notification for Underground Storage Tanks) is to be completed for each location containing underground storage tanks regulated under 527 CMR 9.00. If more than five tanks are 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. The local fire department will issue the permit portion of the FP-290, however, registration is not complete until the FP- 290 is received and checked bY. the UST Regulatory Compliance Unit. All questions on this form are to be answered. Incomplete forms will be returned.

1 "New Facility" means a tank or tanks located at 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 pro-vided, please indicate distance and direction from closest intersection, e.g., (facility at 199 North Street is located) 400 yards southeast of Commons Road (intersection).

A. Facility Number _

B. Date Entered

C. Clerk's Initials

D. Comments

Notification Required and location of the tank, and the type and quantity of substances stored Fire Prevention Form FP-290 is to be used as Notification, Registra- in such tank, or which were stored in such tank before the tank ceased tion, and Permit for underground storage tanks and tank facilities regu- being in operation if the tank was removed from beneath the surface of the lated under 527 Code of Massachusetts Regulations 9.00. No regulated ground pnor to the submittal of such notice to the department. If the tank underground storage tank facility shall be installed, maintained, replaced, was abandoned beneath the surface of the ground prior to the submittal of substantially modified or removed without a permit (FP- 290) issued by such notice to the department, such notice shall also specify, to the extent the head of the local fire department. The owner of any storage facility known to the owner or operator, the date the tank was abandoned in the shall within seven working days notify the head of the local fire department ground and all methods used to stabilize the tank after the tank ceased and the Dept. of Fire Services of any change in the name, address, or being in operation.

telephone number of the owner or operator of a storage facility subject to

Exception: (a) a farm or residential tank of 1,100 gallons or less capacity used regulation by Chapter 148, Mass. General Law and by 527 CMR 9.00.

for storing motor fuel for noncommercial purposes, or (b) a tank used for Underground Storage Tanks storing heating oil for consumptive use on the premises where stored Each owner of an underground tank first put into operation on or after Jan. are not required to be registered under 527 CMR 9.00.

1, 1991, shall, within thirty days after the tank is first put into operation, Penalties: Any owner who knowingly fails to notify or submits false informa-notify the Department of Fire Services (the department) of the existence tion shall be subject to a civil penalty not to exceed $25,000 for each tank of such tank, specifying, to the extent known, the owner of the tank, date for which notification is not given or for which false information is submitted. of installation, capacity, type, location, and uses of such tank. By no later (MGL Chapter 148, section 38H, 527 CMR 9.00) than Jan. 31, 1991, each owner of an underground storage tank that was in operation at any time after Jan. 1, 1974, regardless of whether or not Where to Notify? Two comP.leted notification forms should both be signed by such tank was removed from beneath the surface of the ground at any the tank owner. One copy will be provided to the fire department, and fhe tank time, shall notify the department of the existence of such tank, specifying, owner shall send a separate copy to the address at the top of this page.

to the extent known, the owner of the tank, date of installation, capacity, When to Notify? 1. Owners of storage tanks in use or that have been taken type, location of the tank, and the type and quantity of substances stored out of operation must notify within thirty days. in such tank, or which were stored in such tank before the tank ceased being in operation if the tank was removed from beneath the surface of the Owners and Operators of Regulated StorageTank Systems must maintain ground pnor to the submittal of such notice to the department. Such notice records certifying that all leak detection, inventory control and tightness shall also specify, to the extent known, the date the tank was removed testing requirements for the Regulated Stora9eTank System are current.

from beneath the surface of the ground prior to the submittal of such notice These records must be readily available for inspection.

to the department. The operator of any tank that has no owner or whose owner cannot be definitely ascertained, shall notify the department of the existence of such tank, specifying, to the extent known, any information relating to ownership of the tank, and date of installation, capacity, type, I. OWNERSHIP OF TANK(s) II. LOCATION OF TANK(S)

Owner Name (Corporation, Individual, Public Agency, or Other Entity) Give the geographic location of tanks by degrees, minutes, and seconds.

Example: Lat. 42, 36, 12 N Long. 85, 24, 17W

Do.c\ mov\� �t( � ()s:\ (iCS � 3> Latitude '·11, �/s i"�") N Longitude ]1,()0 I$<& {,U ll.{o ((u\S, ((ooJ Street Address

Mailing Address (if different from street address) Facility Name or Company Site identifier, as applicabi'e

No. O"c-rM(.\u\V'\ Cfl& o;nt.f7 l"lo C Cos<::> G.,,.:wd City State Zip Code Street Address (P.O. Box not acceptable - see instructions #2)

\5 flS·to � No. D(!.rt01(,)v\� MA O;).Jl{ 7 County City Zip Code

')"cg 'Yl'-1 � 7{,p/ b(\.�-\0\ State

Phone Number (Include Area Code) Owner's Employer Federal ID # County

Page 2 FP-290 (revised 05/08)

Ill. TYPE OF OWNER

D Federal Government D Commercial

D State Government (storage and sale)

!&'Local Government Private

(storage and use)

IV. INDIAN LANDS

D Tanks are located on land within an Indian Reservation or on other trust lands.

D Tanks are owned by native American nation, tribe, or individual.

v. TYPE OF FACILITY

Select the Appropriate Facility Description: (check all that apply)

-- TruckingfTransport

-- Utilities

-- Residential

-- Farm

_L_ Other (explain) F,r� v�t21·

VI. CONTACT PERSON IN CHARGE OF TANKS

Name: t�chti<J A \(0�� Address: Phone Number (include area code):

Job Title: Ch,e f tLlo C (oS3 l\;;aJ Home: '50'6- �O,l/- l, l{e(

�- DaAMl'l\)"\\\ MA Business: 56 �- � '1'--1-Ct/l(.,_I

VII. FINANCIAL RESPONSIBILITY

DI have met the financial responsibility requirements in accordance with 527 CMR 9.00.

i- ------------------------------------------ Check all that apply:

IX! Self Insurance D Guarantee □ Letter of Credit

D Commercial Insurance □Surety Bond □Trust Fund

□Risk Retention Group D State Fund □Other Method Allowed - Specify

Provide policy information, certificate of compliance information or other verification.

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 �o

2. Tank site located in surface drinking water supply protection area □Yes DH1o

3. Tank site located within 100 feet of a wetland □Yes q;(c>

4. Tank site located within 300 feet of a stream or water body □Yes �

IX. DESCRIPTION OF STORAGE TANKS AND PIPING (COMPLETE FOR EACH TANK AT THIS LOCATION)

Tank Identification Number Tank No._J

1. Tank status

a. Tank mfr's serial # (if known)

Tank No.- Tank No.-- Tank No.-- Tank No.

b. Currently in Use I '$. I I I I I I I I I c.

Temporarily Out of Use (Start Date) I I d.

Permanently Out of Use I I

I I I I I I I I

I I I I I I I I

e. Underground storage tank (UST)

2. Date of Installation (mo./day/yr.)

3. Estimated Total Capacity (gallons)

�UST

10 /I')\°\ I

C..ooo

OUST OUST OUST OUST

Gas Station Marina

Petroleum Distributor Railroad

Airport Federal - Military

Aircraft Owner Industrial

Vehicle Dealership -- Contractor

Page 3 FP-290 (revised 05/08)

I

I I

Tank Identification Number (cont.) Tank No._l_ Tank No.-- Tank No.-- Tank No. Tank No.

4. Substance Currently or Last Stored

a. Gasoline

Motor vehicle or other use

b. Diesel

Motor vehicle or other use

c. Kerosene

d. Fuel Oil*

* "Consumptive Use" tanks need not be registered.

"Consumptive Use" fuel used exclusively for area heating and/or hot water.

e. Waste Oil

f. Other, Please specify lv(���I 10MV □Marina

□other

IV('.i.joooJ I !ItMv □Marina

□other

I I OMV □Marina

□other

I OMV □Marina

□other

OMV □Marina

□other

I I OMV □Marina

□other

OMV

□Marina other

I I

OMV

□Marina other foo

I l OMV □Marina

□other

I I OMV □Marina

□other

Hazardous Substance (other than 4a thru 4e above)

CERCLA name and/or

CAS number

1----------------- Mixture of Substances

Please specify

I I I I I I I I I I

1oo------

I I I I I I I I I I

5. Material of Construction - Tank (mark only one)

Bare steel (includes asphalt, galvanized and epoxy coated)

Cathodically protected steel

Composite (steel with fiberglass)

Fiberglass reinforced plastic (FRP)

Concrete

Unknown

Other

I t/£

I

I

I I I

I I

I I

I

6. Type of Construction-Tank

(mark only one) Single walled

Double walled

Unknown

Other

Please specify

Is tank lined?

Does tank have excavation liner?

I I

I

□Yes�

I

I

□Yes □No

I I

□Yes □No □Yes □No

FP-290 (revised 05/08) Page 4 v

Tank Identification Number (cont.) Tank No.- 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

Fiberglass reinforced plastic (FRP)

Flexible

Copper

Unknown

Other

Please specify

8. Type of Construction - Piping (mark only Single walled

Double walled

Unknown

Other

Please specify

Has piping been repaired?

Is piping gravity feed?

Date

I I

I

□Yes �o

I I

I I I I I

I I

1. Installation

X. INSTALLATION COMPLIANCE

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

(mark only one)

A. Double-wall tank - Interstitial monitoring

B. Approved in-tank monitor

C. Soil vapor monitoring (check one below)

□Monthly □Continuous

I I

I v

I

I I

Tank I

[i]

I I

I I

I I

Tank ..

I I

I I

I I

Tank

I I

I I

I I

I I

I I

E. Other method allowed by 527 CMR 9.00.

FP-290 (revised 05/08) Page 5

M

Tank Identification Number (cont.) TankNo.J_ Tank No. Tank No.-- Tank No. Tank No.

3. Piping Leak Detection (mark only one)

A. Pressurizec;I

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)

□ Interstitial space monitor

□ Line tightness test

C. Suction: Check valve at dispenser only

(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

A. Spill containment device installed

B. Overfill prevention device installed

7. Daily Inventory 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) A. Sacrificial Anode Type

1-

[Z]

Tank

Piping

Piping

1---

Tank

Piping

Tank

Piping

Tank

Piping

Tank

Piping

B. Impressed Current Type □ □ □ □ □ □ □ □ □ C.

Date of Last Test t /y-, /oq .

Date of Last Third Party Inspection: .J lJ:iJo�

XI. CERTIFICATION (Read and sign after completing all sections) NOTE: Both the copy being sent to the Dept. of Fire Services and the copy forwarded to 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, I believe that the submitted information is true, accurate, and complete.

Name and official title of owner or owner's authorized representative (Print) Signature: Date:

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