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Home My WebLink AboutMP23-087 t tt 4.oJJ�V 190 VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury v ww.ryebrook.or� TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE July 25,2023 Sebastian Bartolotta&Tracey Bartolotta 3 Jacqueline Lane Rye Brook,New York 10573 Re: 3 Jacqueline Lane, Rye Brook,New York 10573 Parcel ID#: 135.35-1-58 As per the Certification letter from Enviroshield Inc. dated July 19, 2023, the removal of an underground oil tank under Mechanical Permit#23-087 issued on 6/8/2023 has been satisfactorily completed. Sincerely, Steven E. Fews Building& Fire Inspector /to �E BRC�� • �9�2 BUILDING DEPARTMENT 04 UILDING INSPECTOR ❑ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 King Street• Rye Brook,NY 10573 (914) 939-0668 FAx (914) 939-5801 www ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - -_- - - - -- - - - - o� I ADDRESS : DATE' PERMIT# A?i ISSUED: SECT: BLOCK: LOT: LOCATION: v OCCUPANCY: 2- 1 ❑ Violation Noted THE WORK IS... ❑ PASSED ❑ FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas dt�1 C \j ❑ FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION y ❑ FINALTV ❑ OTHER c�U ` 00 CUP C?S1Ca�'v S 44 pQ w ^d \ � ; W � oN E I... � z aa� 00 Ln CD toen O Qom ° ao o >tu sG O Z o �� en 1 � a D opvy W '� CC o = O V w '� a v •p C = o 0-4 7 O a pFy ru- w �W1rvo � � v� to n v ;� � z � � � � � ; � o °° {!� rrahh' U v ° W %0 Z u O M F oo a ()s b eq �o0G � � _ 0.0 Omni 16 V x U F+1 O �0.4 o . v V o Co v W o ° V v O u o 00 V � g ° x H w O A o � •� M p w z H a ® � . u r ti acu �I PQl NI a1 0-41 Volx0 14 UIL - MET B O YL VIL O OOK 938 KING ET R�E BR ,NY 10573 N - 5 2023 4 -0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Avelication for Permit to Remove, Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT #: /-//Q 3 --OR Approval Date: �023 Permit Fee: $ Approval Signature: Other: Disapproved: (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERMIT&CERTIFICATE OF COMPLIANCE: 1. Application Completed by Bonded, Licensed Contractor. 2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder) 3. Your contractor's valid proof of workers compensation insurance. (Form#C 105.2 or Form#U26.3 /or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal,Abandonment, or Installation: $185-00 per Tank. 5. Dig Safely New York#(dial 8 l 1)-. CO-;;i b"3 - - St ck 6. Inspection by Building Department for removal /abandonment and/or installation. 7. Submit all Manifests& Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated,�� rah 3 , is hereby made to the Building inspector of the Village of Rye Brook for a permit to remove,abandon,and/or install a Fuel Tank as herein described. The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County, State& Federal laws, codes, rules and regulations. Indicate Permit Type: Installation ( )•Removal(✓S•Abandonment( }I Above Ground ( }• Buried in Ground (--y 1. Address: v�-i" ` �`-Q`} SBL: 135 367-1 5? Zone: 2. Property Owner&Address: �2 SA6t�Si:o,.s ��r'T�lo�tCa 3 J�CQ�y��;n� L.tyL,€ Phone#: '�t``S - - 3X13 Cell#: email: 3. Contractor&Address: `'` Phone#: 3g� 5U- x Cell#: email: ,�� 4. Applicant: Z,\4 A r-- Phone#: D3'3�o jd.1�-lr Cell#: email: �► � �.�'`'Z"54,`�'•Cam_ r` 5. Indicate Fuel Type: Fuel Oil( L.P. Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank; 7. Exact Location(s)of each Tank: t 8/12/2021 Cbar\ +C; r�'-Q0 STATE OF N£ COUNTY OF RHE&TER ) as: being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the IEYN,j. .-.a S ' I au, lr C, for the legal owner and is duly authorized to make and file this application_tindicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations. Sworn to before me this �� ` Sworn to before me this o �- day of WI ,20,P'L day of .20 Signature of roperty Owner Signature of Applicant Pint N f Prop Owner Print Name of Applicant 14, Q r)J J� t-Q 5 Notary Public Notary Public SEAN LY-LE NOTARYP6LIC l.`.........,. My Commission Expires P;q 31,202 PANIELLY NOVOLI-SANTOS This application must be properly completed in its entirety and must thee,State of Connecticut signature(s) of the legal owner(s) of the subject propeity, and the app is i9t11tr1i1Chri*1ba IsoarMay 27,2026 provided. Any application not properly completed in its entirety and/or not properly st deemed null and void and will be returned to the applicant- 2 8/12/2021 �Q Clean, Preserve...Protect S ��► �� Environmental Specialists � July 19,2023 Mr. Dominic Falcone Westmore Fuel D ECIEWIED 86 North Water Street Greenwich,CT 06830 J U L 2 4 2023 Subject: Tank Removal, July 11, 2023 VILLAGE OF RYE BROOK Bartolotta Residencc BUILDING DEPARTMENT 3 Jacqueline Lane Rye Brook,New York Permit #MP-23-087 Dear Mr. Falcone: On July 11, 2023, Enviroshield staff completed the removal of one underground 550-gallon fuel oil tank located at the subject property. The tank removal process is depicted in three site photographs included with this report. Prior to the removal of the tank, all remaining liquid, sludge sediment, and rinse water were pumped and cleaned from the tank for disposal by Enviroshield, Inc., a State of New York licensed waste transporter at Tradebe Treatment and Recycling of Bridgeport LLC, 50 Cross Street, Bridgeport, Connecticut. Attached is a copy of the waste transport Bill of Lading. The top of the tank was exposed using an excavator and enough soil was removed from the excavation to pull the tank from the ground. The tank was thoroughly inspected for rust, cracks, holes, or other physical characteristics,which could have been the cause of a fuel release. No evidence of a fuel release was observed. Soil samples obtained from the tank grave were screened using the Photo Ionization Detector (PID); the results of the field screening indicated no evidence of a fuel release. A soil sample was collected from the bottom of the excavation, in the area presumed to be most impacted, and submitted to Complete Environmental Testing (CET), a State of New York certified environmental laboratory for analysis by STARS 8260 and 8270. Consistent with New York State — Department of Environmental Conservation (NYS-DEC) requirements, these are the required analyses for oil tank removal in New York State. As indicated in the attached Complete Environmental Testing (CET) report #3070207 (and the attached Table 1 —NYSDEC CP-51 Regulatory Comparison to Soil Sample Result)the reported results for the sample tested were all below the current NYS-DEC Guidance Values for the constituents tested. CT Home Improvement Contractor FEC.0582591 —Westchester Home Improvement License WC-27310-H14 250 Moffitt Street, Stratford, CT 06615 (203) 380-5644 FAX(203) 378-8736 www.enviroshield.com- info@enviroshield.com Page 2 of 2 July 19,2023 Bartolotta Residence 3 Jacqueline Lane Rye Brook,New York The tank was transported, cleaned, and disposed of at P.C. Metals, Inc., 270 Central Avenue, Bridgeport, Connecticut in a manner consistent with industry standards and in compliance with all Local,State and Federal Codes and Regulations.The tank grave was backfilled and brought to grade. Based on visual observations, PID field screening and laboratory analysis, Enviroshield found no indication of the tank system's failure. If you have any questions concerning this work, please do not hesitate to contact me at your earliest convenience at (203) 380-5644. Sincerely, Enviroshield Inc. s CUB collard I3ochicchio Senior Project Manager Enclosures cc: Village of Rye Brook Building Department via email torlando&ryebrook.org Permit#MP-23-087 v Clean, Preserve...Protect r Environmental Specialists Site Photograph Page 1 of 3 3 Jacqueline Lane Rye Brook, NY 10573 P.O.Box 12%.250 Moffitt St., Stratford,CT 06615 (203)3W5644 (800)394-2268 FAX(203)3784736 www.enviroshield.com info(a,enviroshield.com Clean, Preserve...Protect j �► Environmental Specialists Site Photograph Page 2of3 3 Jacqueline Lane Rye Brook, NY 10573 Al Rye Brook,New York,United States 7 M>^ •fir� :..:- t �' s�;' '„ -'t+' t Jacqueline 105739 USA P.O.Box 12%.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)3784736 www.enviroshield.com info(a-)enviroshield com Clean, Preserve...Protect Environmental Specialists Site Photograph Page 3of3 3 Jacqueline Lane Rye Brook, NY 10573 to I ' .tw rsx4 •.r r •Y a✓ Rye Brook, Brook,3 Jacqueline Ln, Rye USA P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www.enviroshield.com info(@enviroshield.com 3' Clean, Preserve...Protect Environmental Specialists BILL OF LADING DESCRIPTION: Check applicable waste ID: (NA1993) Fuel oil / diesel /waste oil _ (UN1203) Gasoline _ (UN1223) Kerosene Off-Specification commercial chemical product fuel (applicable in CT only) _ Waste, NON-RCRA, Liquid, N.O.S. (Oil/Water mix) Non-Haz, None (applicable in NY State) Water only (no fuel waste). Date: ac Total Quantity: gallons Generator Name: (AIO-Shlik EU?.j Site Address: LL(f)jl2e— C-� City: r _�� State: / l)Zip: I 0,573 Telephone: , o�r,��'�3 f`�� W Generator/Agent for Signature: , Transporter: Enviroshield, Inc., 250 Moffitt Stre6. CT-09 �tf.!4 , CT 06615 203-380-5644 Connecticut: CT-HW�9 ew YoWestchester County NY: WC-27310-H14; nectic H.I.C.05825 Driver Signature: Destination/Facility: Tradebe Treatment a cycling of Bridgeport LLC 50 Cross Street Bridgeport,Connecticut 06610 Approval Code: (SEE BACK FOR HAZARD/SAFETY/RESPONSE DETAILS) F:\Temp1ates\Misc\8i11 of Lading Uquid.docx P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www,enviroshield.com info enviroshield.com 80 Lupes Drive Tel:(203)377-9984 Stratford,CT 06615 Fax:(203)377-9952 (VU e-mail:cetl@cetlabs.com Wilf fNVIRONMIN1At TITING, E Client: Mr. Richard Louis Enviroshield,Inc. P.O.Box 1296 Stratford,CT 06615 Analytical Report CET# 3070207 Report Date:July 19,2023 Project:3 Jacqueline Lane Connecticut Laboratory Certificate:PH 0116 New York NELAP Accreditation: 11982 Massachusetts Laboratory Certificate:M-CT903 Pennsylvania Laboratory Certificate:68-02927 Rhode Island Laboratory Certificate: 199 Page 1 of 12 CET#:3070207 Project:3 Jacqueline Lane SAMPLE SUMMARY The sample(s)were received at 4.40C. This report contains analytical data associated with following samples only. Sample ID Laboratory ID Matrix Collection Date/rime Receipt Date Tank Grave 3070207-01 Soil 7/11/2023 10:30 07/12/2023 Analyte:Percent Solids[SM 2540 G1 Analyst:CAS Matrix:Soil Date rime Laboratory ID Client Sample ID Result RL Units Dilution Batch Prepared Analyzed Notes 3070207-01 Tank Grave 83 1.0 % 1 B301232 07/12/2023 07/13/2023 07:58 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 2 of 12 CET#:3070207 Project:3 Jacqueline Lane Client Sample W Tank Grave Lab ID:3070207-01 Semivolatile Organics Analyst:STP Method: EPA 8270D Matrix:Soil Result RL Date/Time Analyte (ug/kg dry) (ug(kg dry) Dilution Prep Method Batch Prepared Analyzed Notes Naphthalene ND 120 1 EPA3545A B3G1353 07/13/2023 07/17/202312:41 Acenaphthylene ND 120 1 EPA3545A B3G1353 07/132023 07/171202312:41 Acenaphthene ND 120 1 EPA3545A B3G1353 07/13/2023 07/17/202312:41 Fluorene ND 120 1 EPA3545A B3G1353 07/13/2023 07/17/202312:41 Phenanthrene 120 120 1 EPA3545A B3G1353 07/132023 07/17/202312:41 Anthracene ND 120 1 EPA3545A B3G1353 07/13/2023 07/17202312:41 Fluoranthene 250 120 1 EPA3545A 83G1353 07/132023 07/17202312:41 Pyrene 210 120 1 EPA3545A B3101353 07/132023 07/17202312:41 Benzolalaothracene 140 120 1 EPA3545A 33G1353 07/132023 07/17202312:41 Cbrysene 140 120 1 EPA3545A B3G1353 07/132023 07/17202312:41 Benzolb]fluorantbene 160 120 1 EPA3545A B3151353 07/132023 07/17202312.41 Benzo[k]fluoranthene ND 120 1 EPA3545A B3151353 07/132023 07/17202312:41 Benzolalpyrene 150 120 1 EPA3545A B3G1353 07/132023 07/17202312:41 Indeno[1,2,3-cd]pyrene ND 120 1 EPA3545A B3101353 07/132023 07/17202312:41 Dibenz[a,h]anthmcene ND 120 1 EPA3545A B3151353 07/13/2023 07/17202312:41 Benzolg,h,llperylene 120 120 1 EPA3545A 83G1353 07/13/2023 07/17202312:41 Surrogate:Nitrobemene45 36.5% 30-130 B3G1353 07/132023 0711712023 12:41 Surrogate:2-Fluorobiphenyl 62.3% 30-130 B3G1353 07/132023 0711712023 12:41 Surrogate:Terphenyl-d14 86.4% 30-130 B3G1353 07/13t2023 0711712023 12:41 Volatile Organics Analyst:MH Method:EPA 8260C Matrix:Solt Result RL Datrrrime Analyte (ug/kg dry) (ug/kg dry) Dilution Prep Method Batch Prepared Analyzed Notes Methyl-t-Butyl Ether(MTBE) ND 5.6 1.87 EPA5035A-L B3151241 07/122023 07/12202323:12 Benzene ND 5.6 1.87 EPA5035A-L 133G1241 07/12/2023 07/12202323:12 Toluene ND 5.6 1.87 EPA5035A-L B3101241 07/122023 07/12202323:12 Ethylbenzene ND 5.6 1.87 EPA5035A-L B3101241 07/12/2023 07/12202323:12 m+pXylenes ND 11 1.87 EPA5035A-L B3G1241 07/122023 07/12202323:12 o-Xylene ND 5.6 1.87 EPA5035A-L B3G1241 07/122023 07/12202323:12 Isopropylbenzene ND 5.6 1.87 EPA5035A-L B3G1241 07/12/2023 07/12202323:12 n-Propylbenzene ND 5.6 1.87 EPA5035A-L B3431241 07/122023 07/12202323:12 1,3,5-Trimethylbenzene ND 5.6 1.87 EPA5035A-L B3G1241 07/122023 07/12202323:12 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 3 of 12 CET#:3070207 Project:3 Jacqueline Lane Client Sample ID Tank Grave Lab ID:3070207-01 Volatile Organics Analyst:MH Method:EPA 8260C Matrix:Soil Result RL Date/Time Analyte (ug(kg dry) (ug/kg dry) Dilution Prep Method Batch Prepared Analyzed Notes tert-Butylbenzene ND 5.6 1.87 EPA 5035A-L B3G1241 07/12/2023 07/12/2023 23:12 1,2,4-Trimethylbenzene ND 5.6 1.87 EPA 5035A-L B3G1241 07/12/2023 07/12/2023 23:12 sec-Burylbenzene ND 5.6 1.87 EPA 5035A-L B3G1241 07/12/2023 07/12/2023 23:12 4-Isopropyltoluene ND 5.6 1.87 EPA 5035A-L B3G1241 07/12/2023 07/12/2023 23:12 n-Butylbenzene ND 5.6 1.87 EPA5035A-L 133G1241 07/12/2023 07/121202323:12 Naphthalene ND 11 1.87 EPA5035A-L B3G1241 07/12/2023 07/12/2023 23:12 Surrogate:1,1-Dichloroe/hane-d4 95.5% 70-130 B3G 1241 07/12/2023 0711212023 23:12 Surrogate:Toluene-& 98.4% 70-130 B3G 1241 07/12/2023 0711212023 23:12 Surrogate:4-Bromofluorobenzene 99.4% 70-130 B3G1241 07/12/2023 0711212023 23:12 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetiabs.com Page 4 of 12 CET#:3070207 Project.3 Jacqueline Lane QUALITY CONTROL SECTION Batch B3G1241 -EPA 8260C Result RL Spike Source %Rec RPD Analytc (ug/kg) (ug/kg) Level Result %Rec Limits RPD Limit Notes Blank(B3G1241-BLKI) Prepared:7/12/2023 Analyzed:7/1 212 0 2 3 Methyl-t-Butyl Ether(MTBE) ND 2.5 Benzene ND 2.5 Toluene ND 2.5 Ethylbenzere ND 2.5 m+p Xylenes ND 5.0 o-Xylene ND 2.5 Isopropylbcnzene ND 2.5 n-Propylbenzene ND 2.5 1,3,5-Trimcthylbenzene ND 2.5 tert-Butylbenzene ND 2.5 1,2,4-Trimethylbenzene ND 2.5 sec-Butylbenzene ND 2.5 4-Isopropyltoluene ND 2.5 n-Butylbenzenc ND 2.5 Naphthalene ND 5.0 Surrogate:l,1-Dichloroethaned4 104 70.130 Surrogate:Toluene-& 99.9 70-130 Surrogate:4-Bromofluorobemene 101 70-130 LCS(B3G1241-B51) Prepared:7/12/2023 Analyzed:7/12/2023 Methyl-t-Butyl Ether(MTBE) 45.8 2.5 50.000 91.7 70-130 Benzene 45.3 2.5 50.000 90.5 70-130 Toluene 46.5 2.5 50.000 93.0 70-130 Ethylbenzene 46.7 2.5 50.000 93.3 70-130 m+p Xylenes 93.4 5.0 100.000 93.4 70-130 o-Xylene 46.7 2.5 50.000 93.3 70-130 Isopropylbenzene 46.4 2.5 50.000 92.8 70-130 n-Propylbenzene 46.1 2.5 50.000 92.3 70-130 1,3,5-Trimethylbenzene 46.1 2.5 50.000 92.1 70-130 ten-Butylbenzene 45.7 2.5 50.000 91.3 70-130 1,2,4-Trimethylbenzene 45.9 2.5 50.000 91.7 70-130 sec-Butylbenzenc 46.0 2.5 50.000 92.0 70-130 4-Isopropyltoluene 46.2 2.5 50,000 92.3 70-130 n-Butylbenzene 46.5 2.5 50.000 92.9 70-130 Naphthalene 47.8 5.0 50.000 95.6 70-130 Surrogate.1.1-Dichloroethane-d4 104 70-130 Surrogate.Toluened8 101 70-130 Surrogate.4-Bromofluoroben.ene l01 70-130 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 5 Of 12 CET#:3070207 Project:3 Jacqueline Lane Batch B3G1353-EPA 8270D Result RL Spike Source %Rec RPD Analyte (ug(kg) (ug/kg) Level Result %Rec Limits RPD Limit Notes Blank(B3G1353-BLKI) Prepared:7/13/2023 Analyzed:7/17/2023 Naphthalene ND 100 Acenaphthylene ND 100 Acenaphthene ND 100 Fluorene ND 100 Phenanthrene ND 100 Anthracene ND ]00 Fluoranthene ND 100 Pyrene ND 100 Benzo[a]anthracene ND 100 Chrysene ND 100 Bertzo[b]fluoranthene ND l00 Benzo[k]fluoranthene ND l00 Benzo[a]pyrene ND 100 lndeno[1,2,3-cd]pyrene ND 10o Dibenz[a,h]anthracene ND 100 Benzo[g,h,i]perylene ND 100 Surmgale:Nitrobenzene-d3 57.6 30.130 Surrogate.'1-Fluorobiphenv/ 63 1 30.130 Surrogate:Terphenyl-dl4 77.7 30-130 LCS(83G1353-BSI) Prepared:7/13/2023 Analyzed:7/17/2023 Naphthalene 1990 100 4,000,000 49.9 40-140 Acenaphthylene 2250 100 4,000.000 56.2 40-140 Acenaphthene 2270 100 4,000.000 56.8 40-140 Fluorene 2330 100 4,000.000 58.4 40-140 Phenanthrene 2360 100 4,000.000 58.9 40-140 Anthracene 2430 100 4,000.000 60.8 40-140 Fluoranthene 2560 100 4,000.000 64.1 40-140 Pyrene 2580 100 4,000.000 64.5 40-140 Benzo[a]anthracene 2400 100 4,000.000 60.1 40-140 Chrysene 2440 100 4,000.000 60.9 40-140 Benzo[b]fluoranthene 2400 100 4,000.000 59.9 40-140 Benzo[k]fluoranthene 2360 100 4,000.000 59.0 40-140 Benzo[a]pyrene 2500 100 4,000.000 62.6 40-140 Indeno[1,2,3-cd]pyrene 2590 100 4,000.000 64.7 40-140 Dibenz[a,h]anthracene 2590 10o 4,000.000 64.8 40-140 Beazo[g,h,i]perylene 2640 100 4,000,000 66.0 40-140 Surrogate:Nitrobenzene-d5 47.3 30-130 Surrogate:2-Fhmrobipheny/ 48.1 30-130 Surrogate:Terphenyl-d14 61.1 30-130 Matrix Spike(B3G1353-MSl) Source:3070207-01 Prepared:7/13/2023 Analyzed:7/17/2023 Naphthalene 2650 120 4,801.876 ND 55.2 40-140 Acenaphthylene 3050 120 4,801.876 ND 63.4 40-140 Acenaphthenc 3080 120 4,901.876 ND 64.1 40-140 Fluorene 3190 120 4,901.876 ND 66.5 40-140 Phenanthrenc 3630 120 4,801.876 123 73.1 40-140 Anthracene 3400 120 4,801.876 ND 70.7 40-140 Fluoranthene 4440 120 4,801.876 255 87.2 40-140 Pyrene 4230 120 4,801.876 212 83.6 40-140 Benzo[a]anthracene 3790 120 4,801.876 137 76.1 40-140 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 6 Of 12 CET#:3070207 Project:3 Jacqueline Lane Result RL Spike Source %Roc RPD Analyte (ug/kg dry) (ug/kg dry) Level Result %Rec Limits RPD Limit Notes Matrix Spike(B3G1353-MSI)-Continued Source:3070207-01 Prepared:7/13/2023 Analyzed:7/17/2023 Chrysene 3790 120 4,801.876 136 76.1 40-140 Benzo[b]fluoranthene 3730 120 4,801.876 160 74.3 40-140 Benzo[k]fluoranthene 3660 120 4,801.876 80.6 74.6 40-140 Benzo[a]pyrene 3940 120 4,801.876 152 78.8 40-140 Indeno[1,2,3-cd]pyrene 3970 120 4,801.876 ND 82.7 40-140 Dibenz[a,h]anthmcene 3620 120 4,801.876 ND 75.3 40-140 Benzo[g,h,i]perylene 4130 120 4,901.876 122 83.5 40-140 Surrogate:Nitrobenzene-6 60.8 30-130 Surrogate:2-Fluorobiphenyl 60.4 30-130 Surrogate:Terphenyl-d14 79.8 30-130 Matrix Spike Dup(83G1353-MSD1) Source:3070207-01 Prepared:7/13/2023 Analyzed:7/17/2023 Naphthalene 2150 120 4,801.876 ND 44.7 40-140 20.9 30 Acenaphthylene 2690 120 4,801.876 ND 55.9 40-140 12.6 30 Acenaphthene 2720 120 4,801.876 ND 56.7 40-140 12.3 30 Fluorene 2860 120 4,801.876 ND 59.5 40-140 11.1 30 Phenanthrene 2930 120 4,801.876 123 58.4 40-140 21.5 30 Anthracene 2970 120 4,801.876 ND 61.9 40-140 13.3 30 Fluoranthene 3350 120 4,801.876 255 64.5 40-140 27.9 30 Pyrene 3270 120 4,801.876 212 63.7 40-140 25.4 30 Benzo[a]anthracene 3070 120 4,801.876 137 61.1 40-140 20.9 30 Chrysene 3130 120 4,801.876 136 62.4 40-140 19.0 30 Benzo[b]fluomnthene 3010 120 4,801.876 160 59.3 40-140 21.4 30 Benzo[k]fluomnthene 3070 120 4,801.876 80.6 62.3 40-140 17.5 30 Benzo[a]pyrene 3180 120 4,801.876 152 63.1 40-140 21.2 30 ltdeno[1,2,3-cd]pyrene 3320 120 4,801.876 ND 69.1 40-140 17.9 30 Dibenz[a,h]anthmcene 3290 120 4,801.876 ND 68.5 40-140 9.52 30 Beazo[g,h,i]perylene 3420 120 4,801.876 122 68.8 40-140 18.7 30 Surrogate.-Nitrobenzene-d5 48.2 30-130 Surrogate:2-Fluorobiphenyl 51.9 30-130 Surrogate:Terphenyl-d/4 720 30-130 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 7 of 12 CET#:3070207 Project:3 Jacqueline Lane 80 Lupes Drive *PT Tel:(203)377-9984 Stratford,CT 06615 COMRiiE!NVIAONMfN1Al iE511NG,IN(i Fax:(203)377-9952 email:cetl@cetlabs.com Quality Control Definitions and Abbreviations Internal Standard(IS) An Analyte added to each sample or sample extract. An internal standard is used to monitor retention time,calculate relative response,and quantify analytes of interest. Surrogate Recovery The%recovery for non-target organic compounds that are spiked into all samples. Used to determine method performance. Continuing Calibration An analytical standard analyzed with each set of samples to verify initial calibration of the system. Batch Samples that are analyzed together with the same method,sequence and lot of reagents within the same time period. ND Not detected at or above the specified reporting limit. RL RL is the limit of detection for an analyte after any adjustment made for dilution or percent moisture. Dilution Multiplier added to detection levels(MDL)and/or sample results due to interferences and/or high concentration of target compounds. Duplicate Result from the duplicate analysis of a sample. Result Amount of analyte found in a sample. Spike Level Amount of analyte added to a sample Matrix Spike Result Amount of analyte found including amount that was spiked. Matrix Spike Dup Amount of analyte found in duplicate spikes including amount that was spike. Matrix Spike%Recovery %Recovery of spiked amount in sample. Matrix Spike Dup%Recovery %Recovery of spiked duplicate amount in sample. RPD Relative percent difference between Matrix Spike and Matrix Spike Duplicate. Blank Method Blank that has been taken through all steps of the analysis. LCS%Recovery Laboratory Control Sample percent recovery. The amount of analyte recovered from a fortified sample. Recovery Limits A range within which specified measurements results must fall to be compliant. CC Calibration Verification Flags: H- Recovery is above the control limits L- Recovery is below the control limits B- Compound detected in the Blank P- RPD of dual column results exceeds 40% #- Sample result too high for accurate spike recovery. r Connecticut Laboratory Certification PHOI 16 New York NELAP Accreditation 11982 Massachussets Laboratory Certification M-CT903 Rhode Island Certification 199 Pennsylvania NELAP Accreditation 68-02927 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 8 of 12 CET#:3070207 Project:3 Jacqueline Lane All questions related to this report should be directed to David Ditta,Timothy Fusco,or Robert Blake at 203-377-9984. Sincerely, This technical report was reviewed by Jeffrey Smith 1)44z'� 4�' Y. yat// David Ditta Project Manager Laboratory Director This report shall not be reproduced except in full,without the written approval of the laboratory Report Comments: Sample Result Flags: E-The result is estimated,above the calibration range. H-The surrogate recovery is above the control limits. L-The surrogate recovery is below the control limits. B-The compound was detected in the laboratory blank. P-The Relative Percent Difference(RPD)of dual column analyses exceeds 401/o. D-The RPD between the sample and the sample duplicate is high. Sample Homogeneity may be a problem. +- The Surrogate was diluted out. *Cl-The Continuing Calibration did not meet method specifications and was biased low for this analyte. Increased uncertainty is associated with the reported value which is likely to be biased low. *C2-The Continuing Calibration did not meet method specifications and was biased high for this analyte. Increased uncertainty is associated with the reported value which is likely to be biased high. *FI-The Laboratory Control Sample recovery is outside of control limits. Reported value for this analyte is likely to be biased on the low side. *F2-The Laboratory Control Sample recovery is outside of control limits. Reported value for this analyte is likely to be biased on the high side. *I-Analyte exceeds method limits from second source standard in Initial Calibration Verification (ICV). No directional bias. All results met standard operating procedures unless indicated by a data qualifier next to a sample result,or a narration in the QC report. For Percent Solids,if any of the following prep methods(3050B,3540C,3545A,3550C,5035 and 9013A)were used for samples pertaining to this report,the percent solids procedure is within that prep method. Complete Environmental Testing is only responsible for the certified testing and is not directly responsible for the integrity of the sample before laboratory receipt. ND is None Detected at or above the specified reporting limit Reporting Limit(RL)is the limit of detection for an analyte after any adjustment made for dilution or percent moisture. All analyses were performed in house unless a Reference Laboratory is listed. Samples will be disposed of 30 days after the report date. Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 9 of 12 CET#:3070207 Project:3 Jacqueline Lane CERTIFICATIONS Certified Analyses included in this Report Analyte Certifications EPA 8260C in Soil Methyl-t-Butyl Ether(MTBE) CTNY,PA Benzene CTNY,PA Toluene CT,NY,PA Ethylbenzcnc CTNY,PA m+p Xylencs CTNY,PA o-Xylcnc CTNY,PA Isopropylbcnzene CT,NY,PA n-Propylbenzcne CT,NY,PA 1,3,5-Trimethylbcnzenc CTNY,PA tort-Butylbenzcnc CTNY,PA 1,2,4-Trimethylbenzcne CTNY,PA sec-Butylbenzcne CTNY,PA 4-Isopropyltolucnc CT,NY,PA n-Butyibcnzcnc Ci'YY,PA Naphthalene CTNY,PA EPA 8270D in Soil Naphthalene CT,NY,PA Accnaphthylenc CTNY,PA Acenaphthenc CT,NY,PA F luorenc CTNY,PA Phenanthrcnc CT,NY,PA Anthracene CT,NY,PA Fluoranthcnc CT,NY,PA Pyrene CT NY,PA Benzo[alanthracenc CTNY,PA Chrysenc CT,NY,PA Benzo[blfluoranthcne CTNY,PA Benzo[klfluoranthcne CTNY,PA Bcnzo[alpyrcnc CTNY,PA Indcno[1,2,3-cdlpyrcne CT,NY,PA Dtbcnz[a,hlanthraccnc CT,NY,PA Bcnzo[g,h,ilperylenc CTNY,PA SM 2540 G in Soil Pcrccnl Solids CT Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 10 Of 12 CET#:3070207 Project:3 Jacqueline Lane Complete Environ-mental Testing operates under the following certifications and accrcditations: Code Description Number Expires CT Connecticut Public Health PH0116 09/30/2024 NY New York Certification(NELAC) 11982 04/01/2024 PA Pennsylvania DEP 68-02927 05/31/2024 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetiabs.com Page 11 of 12 Z G JO EL a6e d 0 31ON I I I m •1NOO JO1i 1tl1O1 a u. co $ c r a ° . co E �. O m a s ca W w c W U U V 'z c j"W of qEM Paia8ld Plald I O a U Z a ` O o pan(oss.0 « s m OK E o d1O1 k�k m 4 0 m CL dldH `O P401 r d3010 9 t JLl Lu ~ uad f4PONd s vldod 9 " °w y saPpRsad J E U. 3SV❑ XOS 0 s9Od m a� O sVNd OLZ9 J Al 10 UN Z _ Hd131O Q sue6018H 09Z9 mn C T sogewaV ogZ9 W V lsll 10 09Z9 j z a U CS c H¢ W 9 v (sAe0(•S)D46 C ABC-AL f g v Re0 MN LD - g ! to �C W C r3 d a - w m Y m E a 0 u w w ^ Wy' w w r a W W J. W 2 j Y 3 *er c a NN� ip I x W.@ o z " �O~ E E ° a j c Ct y a 1 c EID y w C m Q P t 3yc ��►n ~ NL F ¢ O w w U m V C cfl ' I o � _ 5 J co cn a U �i ¢ ¢ ¢ C� ci U .0m . m Table 1—NYSDEC CP-51 Regulatory Comparison to Soil Sample Result Client: Enviroshield,Inc. Project: Bartoletta 3 Jacqueline Lane,Rye Brook,NY Matrix: Soil 7/11/2023 Thru Collect Dates: 7/11/2023 Lab Number 3070207-01 Sampled Name Tank Grave Sampled Date 7/11/2023 Parameter CAS_Number Value Qual EPA UGOC tuaft d Meth l-t-But I Ether(MTBE) 1634-04-4 NA <5.6 Benzene 71-43-2 60 <5.6 Toluene 108-88-3 700 <5.6 Eth (benzene 100-41-4 1000 <5.6 m+p X lenes XYLMP 260 <11 o-X lene 95-47-6 260 <5.6 isopropyl benzene 98-82-8 2300 <5.6 n-Pro ibenzene 103-65-1 3900 <5.6 1,3,5-Trimeth (benzene 108-67-8 8400 <5.6 tert-Butylbenzene 98-06-6 5900 <5.6 1,2,4-Trimeth (benzene 95-63-6 3600 <5.6 sec-Butylbenzene 135-98-8 11000 <5.6 4-isopropyitoluene 99-87-6 10000 <5.6 n-Butylbenzene 104-51-8 12000 <5.6 Naphthalene 91-20-3 12000 <11 EPA 827W d Acena hthene 83-32-9 20000 <120 Acena hth lene 208-96-8 100000 <120 Anthracene 120-12-7 100000 <120 Benz a Anthracene 56-55-3 1000 14 Benzo a rene 50-32-8 1000 iQ Benzo(b)fluoranthene 205-99-2 1000 140 Benzo( h,i) lene 191-24-2 100000 120 Benzo(k)fiuoranthene 207-08-9 800 <120 Chrysene 218-01-9 1000 in Dibenz(a,h)anthracene 53-70-3 330 <120 Fluoranthene 206-44-0 100000 250 Fluorene 86-73-7 30000 <120 Indeno(1,2,3-cd]pyrene 193-39-5 500 <120 Phenanthrene 85-01-8 100000 = P rene 129-00-0 100000 210 Naphthalene 91-20-3 12000 <120 sM 2540 G % Percent Solids TS NA 83 Notes: Report Generated on:7/19/2023 10:06:07 AM Qualifiers: Exceeds C-51 Criteria Reported Present but not exceeding CP51 Criteria t a e � w 00 � Fs 0 M N oC v n ^N OC ul R L cu w F J 2 00 x 3 ci hc aj Ln rn s O 1 i r � � � � � �. � � = � r � GJ v � mil. • GN pz all it zc C*A z co rry oG O - 00 J R E 0. 0 = v = U Od d' —III: S n. o ° z ° o kgo � w ° o H OH O Z Z " �S u 6 O < eb Z a. v> > a M a �' z OQ BUILDING DEPARTMENT VILLAGE OF RYE BROOK 938 KINc STREF, RYE BROOK, NN' 10573 JUN - 5 2023 (914)939-0068 VILLAGE OF RYE BROOK w-%vw.r�ebrook.org BUILDING DEPARTMENT Application for Permit to Remove, Abandon and/or Install Fuel Storage Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFIC E L SE ONL1 . Approval Date: J 023 Permit Fee: S Approval Signature: Other: T _ Disapproved: �-� (fees are non-refundable) REQUIREMENTS FOR RELEASE OF PERNUT& CERTIFICATE OF COMPLIANCE: 1. Application Completed by Bonded, Licensed Contractor. 2. Your contractor's valid proof of liability insurance. (Village of Rye Brook must be listed as certificate holder) 3. Your contractor's valid proof of workers compensation insurance. (Form#C 105.2 or Form#U26.3/or NY State Workers Compensation Waiver) 4. Fee per Tank: Removal, Abandonment,or Installation: S 185.00 per Tank. 5. Dig Safcly New York#(dial x 1 1): GSt b 3 cc N - '�)t v 6. Inspection by Building Department for removal abandonment and/or installation. 7. Submit all Manifests& Reports(alter work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, is hereby made to the Building Inspector or the Village oFRye Brook for a permit to remove,abandon,and/or install a Fuel Tank as herein described. The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County,State& Federal laws,codes,rules and regulations. Indicate Permit Type: Installation ( ) • Removal(✓S• Abandonment( )/Above Ground ( )• Buried in Ground(-y I. Address: 3 ��'�-Q v�'`nY- �`��- SBL: �3 t� , 3`�I-�4 "Lone: - 2. Property Owner&Address: Phone 4: 'r11I,- - '3,--l3 Cell N: email: 3. Contractor& Address: �n�`Ra►`,.rho y-iO �S o C�of �+2t�3 t3C�i �. �b�� Phone P: ��'� 33� 7 '-r Cell 4: email: _3nq-L �•�� +"� .V'^^ 4. Applicant: Phone f+: D3 33o jd,X�1 Ccll h: email: Lrsr.+� �i�•.toS�+�tSo.C�� 5. Indicate Fuel Type: Fuel Oil L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each Tank: 7. Exact Location(s)of each Tank: L.qc a L!> *4, t 8/l 2,202 I % it'AA o A t'• A 2 ..� /`.� J•Ik.'.�^IGI �. j.�z Al"i� �,� ,. 0 �� ; 0 ,�� 0 ��• 0 fir. 0 • ��:s, 0 '(I. V.. 't1. dni 1 �J. .♦ r•3 `, ♦ ,1 •s �lll :`:'�G. 't/, 1,1 11r�,`,1 t .1 1 , 9'Aad��.l 1,� •T' .', _ �s C«O)1 o��---� 1�1 :a:ii..va�.-... 11 � t%�.; 11+1 ;f.'. t.....11�111 t&. �t+4't.\II��11.:. 3p 111 �•-�`''f� 1 ,`.•'u.,HB"" .:.cs}( . .. . . . . .. . La C'j � O CV 2 Cq LO +( i .. F- c '°tfl O o •� _ section �s L y Q O u' O R. 4 Ltd �! �• Q Z F- Lc. jp f� W cr N ° U F- 8Q o <co)>t l al U V 'L7 rT ��• IS cVC W � � r ,/ �• �t,• �.� .ti G C N .n C7 v <Y•4)1 �i rr��..4t ::•, sr 1 1 �.��, �I�///+�y•� �''�111+111111,k�`" �1 11 ly�w �� NI, .'f�.•�rf,11 h 1 M _ .�'11 ly,. v'` ail• +� ti • sgy g� 1�1`+ 01a 1 �1�•ql era. 1++ti 1 -/1�/• / ,11 11 _ �A � ♦� .•i-;i�A�H� /,�Y.iPP,1�ay�,,,� A�� 1�♦/�•��-I Aj�r�'��y+j•�� A1�1'n�'k.� •.7' A �� ♦�. A�� -f; / `� �. I€ �y2i� "'Ye� >�� h�K k�+7' �,lJ(QA �x'�"'�'� ^�(�'�R•'p'�� D^ ` � �� ?ry S'>'. YNVAI.. \•��i��/� (;�q�1yy :�VN�' V In :i.?�O��O" :'l��Y� 11 \ yr"y� ... ♦ M�..../�• aq '_alvw. Q>�JV�'�J. :.I r,1 �• -e.� •..�. L �^{... ENVIINC-01 MTOMASELLI ACOR�"�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDIYYYY) 512012023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER �`�� ,cT Mary Tomaselli Gowrie Group PHONE 'FAX No: 70 Essex Road AIC No.Ex . ____ - _._ _- - -__-J �.-_I—_—_-_— Westbrook,CT 06498 ;mtomaselli(Mrisk-strategies.com INSURERS)AFFORDING COVERAGE NAIL 0 INSURER A:Nautilus Insurance Compaay__ 17370 INSURED INSURER B:Great_Divide_.Insurance Comp_any_.. 25224 Enviroshield Inc.and E.G.Kost Rental,LLC INSURERC: PO Box 1296 --- —. -- -- 250 Moffitt Street INSURER D-: Stratford,CT06615 INSURERE: _ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 'ADDL;SUB POLICY EFF POLICY EXP I LIMITS TYPE OF INSURANCELTR POLICY NUMBER (MrmD MIDDIVYYY , A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1'�0,0O0 DAMAGE TO RENTED 100,000 cu IMs-MADE X OCCUR IECP01521982-23 12/1/2022 12/1/2023 g X Pollution Liability MEDgx (Anyoneperaen) t 5,000 —--- 1 000,000 X Professional Liab P_ o aADv JURY si__! GEN'L AGGREGATE LIMIT APPLIES PER: GE{JERAL AGGREGATE S 2,000,000 POLICY n j LOG PRODUCTS-COMPIOPAGG 2,000,000 OTHER: _ I _ COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY ) _--._ __ S — ANYAUTO _ SAP1521979-23 12/1/2022 12/1/2023 �OpILY SUURY_(Perpeta�n S OWNED SCHEDULED AU�T�OS ONLY X AUTOS E ODILY INJURY-0— acciden XJ AUTOS ONLY X AUTOS ONNL� eOPERTY E X MCS-90 End1 A UMBRELLA LIAR M OCCUR EACH OCCURRENCE S 1,000,000 X EXCESS LIAO CLAIMS-MADE FX203675211 12/1/2022 12/1/2023 AGGREGATE 1.000,000 DED I X I RETENTION$ 10,0 _ B WORKERS COMPENSATION X I 1 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $_ AND EMPLOYERS'LIABILITY Y WCA 1521980 22 12�1/2022 12/1/2023 1,000,000 _ OFFICENMEMBER EXCLUDED? NIA 1.000,000 (Mandatory in NH) I E.L DISEASE-EA EMPLOYE _ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below _ IS -POLICY LIMIT i DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apace is mqulred) Village of Rye Brook Is listed as Additional Insured for General Liability where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE_ Village of Rye Brook �,•, 1 T 938 King Street J 1 Rye Brook.tRY_t05Z3— -- ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Is.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (203)394-2268 Enviroshield,Inc. Post Office Box 1296 lc.NYS Unemployment Insurance Employer Stratford,CT 06615 Registration Number of Insured Work Location of Insured(Only required if coverage is specifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 060319014 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Commerce&Industry Insurance Company 3b.Policy Number of entity listed in box"l a" WCA 1521980 22 Village of Rye Brook 938 King Street 3c. Policy effective period Rye Brook,NY 10573 12/1/22 to 12/l/23 3d. The Proprietor,Partners or Executive Officers are ■ included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "Y' insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notify the above certificate holder within 10 days IFa policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for oneyear after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Vincent M. Falciizno (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 12/5/2022 (Signature) (Date) Title: Managing Member Telephone Number of authorized representative or licensed agent of insurance carrier: (203)745-0078 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us Laura Petersen From: UDig NY Exactix <tickets@exactix.udigny.org> Sent: Tuesday,June 13, 2023 11:01 AM To: Steven Fews Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 06/13/2023 11:01 To: VIL RYE BROOK PRIMARY Transmitted: 06/13/2023 11:01 00004 Ticket: 06133-001-222-00 Type: Regular Previous Ticket: 05163-001-519-00 ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 3 To: Name: JACQUELINE LN Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: FRONT RIGHT CORNER OF THE HOUSE NearSt: ROCK RIDGE DR Means of Excavation: EXCAVATOR Blasting: N Site marked with white: Y Boring/Directional Drilling: N Within 25ft of Edge of Road: N Work Type: OIL TANK REMOVAL Estimated Work Complete Date: 07/21/2023 Depth of excavation: 8 FEET Site dimensions: Length 10 FEET Width 6 FEET Start Date and Time: 06/22/2023 07:00 Must Start By: 07/07/2023 ------------------------------------------------------------------------------ Contact Name: PAULA ARCURI Company: ENVIROSHIELD Addrl: PO BOX 1296 Addr2: City: STRATFORD State: CT Zip: 06615 Phone: 203-380-5644 Fax: Email: paula@enviroshield.com Field Contact: LENNY BOCHICCHIO Alt Phone: 800-394-2268 Email: len@enviroshield.com Working for: HOMEOWNER ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA CONED SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR i Laura Petersen From: UDig NY Exactix <tickets@exactix.udigny.org> Sent: Tuesday, May 16, 2023 11:32 AM To: Steven Fews Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 05/16/2023 11:31 To: VIL RYE BROOK PRIMARY Transmitted: 05/16/2023 11:31 00011 Ticket: 05163-001-519-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 3 To: Name: JACQUELINE LN Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: FRONT RIGHT CORNER OF THE HOUSE NearSt: ROCK RIDGE DR Means of Excavation: EXCAVATOR Blasting: N Site marked with white: Y Boring/Directional Drilling: N Within 25ft of Edge of Road: N Work Type: OIL TANK REMOVAL Estimated Work Complete Date: 06/16/2023 Depth of excavation: 8 FEET Site dimensions: Length 10 FEET Width 6 FEET Start Date and Time: 05/19/2023 07:00 Must Start By: 06/05/2023 ------------------------------------------------------------------------------ Contact Name: PAULA ARCURI Company: ENVIROSHIELD Addrl: PO BOX 1296 Addr2: City: STRATFORD State: CT Zip: 06615 Phone: 203-380-5644 Fax: Email: paula@enviroshield.com Field Contact: LENNY BOCHICCHIO C Alt Phone: 800-394-2268 Email: len@enviroshield.com Working for: HOMEOWNER ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA CONED SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR i