Fill and Sign the Notice of Proposal to Conduct Outdoor Laser Operations Form

Maine Department of Public Safety Office of the State Fire Marshal 52 State House Station Augusta, Maine 04333-0052 (207) 626-3880 Telephone (207) 287-6251 Fax http://www.maine.gov/dps/fmo/index.htm Application for Coverage by the Groundwater Oil Clean-up Fund For a discharge from an Aboveground Storage Tank DEP Spill Number: Form Provided By: DEP RESPONDER FIRE MARSHAL’S OFFICE WEBSITE Date Application Was Received: Date Application Was Complete: Action: Approved Denied Deductible: $ __________ Signature: ________________________ Date: ________________________ DO NOT SEND ANY MONEY WITH THIS FORM! The rules for this program are established in Title 38 MRSA §568-A. The applicant must be the owner of the tank involved in the discharge. (38 MRSA §562-A The application must be received by the Office of the State Fire Marshal no more than 180 days after the discharge was reported. (This may be waived under specific circumstances.)(38 MRSA §568-A 1 A) Complete this applications based on conditions at the time of the discharge. “Notice of Eligibility” and “Assignment of Deductibles” will be sent to you by certified mail. Be sure to accept this, as it will affect your rights to appeal the decisions. You may use additional paper, as necessary, if you need more room to answer questions. You may submit photographs and other documentation you feel will help in determining the eligibility of your claim. Definitions are at the end of this form. Owner of the Aboveground Storage Tank Mr. First Name: Initial: Mrs. Ms. Mailing Address: City: State: Telephone: Email: Last Name: ZIP/Postal Code: Total Aboveground Storage Capacity Owned: _____________ US Gallons This figure is required for approval of this application! This is the total capacity of ALL aboveground tanks that the applicant owns in the State of Maine, not just the capacity of the tank involved in the discharge. Include tanks at the applicant’s primary residence, seasonal properties, business properties, and all properties you rent or lease to others. Include tanks that supply heating equipment and other equipment such as generators, and tanks for storing product to be dispensed into vehicle or equipment fuel tanks or portable containers, and tanks for bulk storage for future distribution. Yes No Has the applicant applied for, or been covered by the Fund for any other discharges? If “Yes”, list the DEP Spill Number, Location, and Date of the discharge, and the amount covered or requested for each request. Groundwater Oil Clean-up Fund Application, v11.4, 08-02-2007, word 1 Facility (Site where the discharge occurred) Name (if any): Physical Address: City: County: Contact Person: Telephone: Telephone: Type of Facility: Single Family Residence Other (Specify): Use of Tank: Supply (Includes residential heating systems and other equipment systems.) Storage (Tanks for fuel for dispensing into vehicles and equipment and portable containers, and tanks for bulk storage of fuels for distribution.) Approval of Tank: Yes No Was the tank approved for use as an aboveground storage tank? (Tanks designed as underground tanks, and portable containers such as 55 gallon drums, are NOT approved for use as aboveground storage tanks.) Protection of Tank: Describe how the tank and piping were protected from physical damage, such as being struck by vehicles, falling snow and ice, falling objects, etc. Inspection and Maintenance: Describe the routine inspection and maintenance of the tank. Outstanding Orders: Yes No Is there an outstanding Statement of Deficiencies, Consent Decree, or Court Order regarding violations of Statutes, Rules and Regulations, or Codes at this facility? (If “Yes”, explain) Location of the Tank: Inside a building Yes No Do the fill and vent pipes terminate outside the building? Yes No Is the tank at least 5 feet from the oil burner? Outside Orientation of the Tank: Horizontal Vertical Base for the Tank: Concrete Floor Dirt or Gravel Concrete Pad Other (Specify): Supports for the Tank: Metal Legs Concrete Blocks, Solid Wood Stand Other (specify): Metal Stand Concrete Blocks, Hollow Wood Blocks Overfill Protection: Vent Whistle Other (Specify): Spill Containment: None Double Wall Tank Dike, Earth None Required Dike, Concrete Other (Specify): Groundwater Oil Clean-up Fund Application, v11.4, 08-02-2007, word 2 Storage Facility Information: Permit Information: Yes No Was there a permit or registration for the facility issued by the Office of the State Fire Marshal? (If “Yes” complete the following:) Name of Permit/Registration Holder: Address of Permit/Registration Holder; City: State: Zip: Permit/Registration Number: Date Permit/Registration was issued: Attach a copy of the Permit or Registration to this Application. Underground Piping: Yes No Was any part of the piping from the tank underground? (If “Yes”, complete the following:) Piping was Constructed of: Galvanized Steel Cathodically Protected Steel Flexible, Non-Metallic Piping was: Single Wall DEP Registration Number: Fiberglass Unknown Other (Specify:) Double Wall Spill Prevention Control and Countermeasures Plan (SPCC): Yes No Was a SPCC plan required for the facility (40 CFR 112)? (Aggregate Aboveground Storage Capacity greater than 1320 gallons) Yes No Was there a SPCC plan for the facility that was prepared by a professional engineer? Discharge Information: Date Discharge Occurred or Was Discovered: Size of Tank Involved: Amount Discharged (If known): Date Discharge Was Reported to DEP: Product: Gasoline (any grade) Diesel fuel #2 fuel oil Kerosene K-1 Waste Oil Other (Specify): Describe how the discharge occurred and locations affected or threatened by the discharge: Describe the clean-up actions: Amount of Coverage Requested: (Submit documentation of costs with this application) $ Costs handled by DEP DEP Responder’s Name: Groundwater Oil Clean-up Fund Application, v11.4, 08-02-2007, word Telephone: 3 Applicant’s Signature Section: By signing this document, the applicant: Certifies that he or she owns or operates the facility, Certifies that the information contained in this application is accurate, Agrees to pay the deductible amount assigned, Agrees to permit access to all properties and buildings under the control of the applicant, for the purpose of conducting inspections and reviewing records, and Acknowledges that he or she understands that falsification of information in this application shall constitute grounds for denial and that pursuant to 38 MRSA §349 3 and/or 17-A MRSA §453, falsification of information contained in this document may be punishable by fines, imprisonment, or both. _______________________ Applicant’s Name (Typed or Printed) ________________ Applicant’s Signature ______________ Date Signed The applicant’s signature is required for this application to be eligible for coverage by the Fund. (38 MRSA 568-A 1 A (2)) Waiver of Deductible: An applicant who is unable to pay the deductible assigned may contact the Maine Department of Environmental Protection (207) 287-7192 after receiving Notice of Eligibility and Assignment of Deductible to request a waiver of deductible. The Maine DEP will inform the applicant of what documentation is required to determine the applicant’s eligibility for a Waiver of Deductible. The Maine DEP will make the decision on eligibility for a Waiver of Deductible. Definitions (for use on this form): Capacity: the nominal capacity of a tank, whether the tank is full, part full, or empty. DEP: Maine Department of Environmental Protection. Discharge: any spill, leak, discharge, or release of a petroleum product Product: any petroleum product such as gasoline, diesel fuel, #2 fuel, kerosene, k-1, waste oil, etc. Groundwater Oil Clean-up Fund Application, v11.4, 08-02-2007, word 4