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HomeMy WebLinkAboutMP23-089 yE,11R t,b �tC � l 1�v4 VVy J,iV4 VV W V VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www�ebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE August 9,2023 Thomas Kavanagh&Doris Kavanagh 90 Windsor Road Rye Brook,New York 10573 Re: 90 Windsor Road, Rye Brook,New York 10573 Parcel ID#: 135.52-3-50 As per the Certification letter from Enviroshield Inc. dated July 31, 2023, the removal of an underground oil tank under Mechanical Permit#23-089 issued on 6/9/2023 has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to '-iE BRCi' cu � • �9�2 BUILDING DEPARTMENT BUILDING 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 - - - - - - - - - - - - - - - - - - - - ADDRESS: J DATE: PERMIT# �` > ISSUED: . I SECT: BLOCK: LOT: LOCATION: Ut `� OCCUPANCY: ❑ Violation Noted THE WORK IS... ❑ PASSED Crx FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING _ ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas gF"UEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL ❑ OTHER a a e a � w 00 w v = CV O N Of rA � � �, ■ cn x a� o r--i ■ : W HRE sk, V a o x M z Q � � o � � w � w ■ xn ~ O sLei a y Ho A > ■ ov�' ` w g xci o o _ O M■.{ I�-1 A C � rya � u y C� � /� _ fr; ti d 4 as W0a � = �! ' _ H ' p � , gwe am o U ■ ' M o z Uz a o 14 U = e Q A w w �Wx � a � � o 00 CY 0 5 'O e z z � � " " � � O D CUD °' ° .� O oLo .o � v o H x o Lu � O C7 Oov a `� t. P-L p w ao U O J vcl •• ~ 0 o �I W P-4 1.4 BUILD Ni� DEPAR MENT U � � � ��E r VIL1ET E OF Ri , oox 938 KING RYE BR ,NY 10573 .fUN - 9 2023 44 0 VILLAGE OF RYE BROOK BUILDING DEPARTMENT Application for Permit to Remove Abandon and/or Install Fuel Stora a Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: 3 -- Approval Date: Permit Fee: S 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: $185.00 per Tank. 5. Dig Safely New York#(dial 811): �6D'"13 - 6m - -13`3 6. Inspection by Building Department for removal/abandonment and/or installation. 7. Submit all Manifests& Reports(after work has been completed). 8. Certificate of Compliance will be provided when all requirements are fulfilled. Application dated, kJ^ •a��3 , is hereby made to the Building Inspector of the Village of Rye Brook for a permit to remove,abandon,and/or install a Fuel Tank as herein described. The applicant and property owner,by signing this document agree that the subject fuel tank(s)will be removed,abandoned and/or installed in conformance with all applicable Village,County, State& Federal laws, codes,rules and regulations. Indicate Permit Type: Installation ( )• Removal Abandonment( )/Above Ground ( }• Buried in Ground I. Address: •^�.�D RQ A-� SBL: �� `,. o�-3—,!5aonc: 2. Property Owner&Address: , gc W'•��So2 Phone#: '15%4 Cell#: email: 3. Contractor&Address: �����2�-S� `tom �� .r'� C52� rt 1 I'zZ, l p66t� Phone#: ' 03 `3� 564t Cell#: email: Cr':n 4. Applicant: C- -te 5LN;tLo :Z- 4 e-, '�� C G �sT2£�x rtaa'�be� ut. Obit$ Phone#: a'o`3 -38 n 5% -•t'-t Cell#: 5. Indicate Fuel Type: Fuel Oil(-Ir- L.P.Gas( )•Gasoline( )•Other( }: 6. Number and Capacity of each Tank: - _:X_n.S q16kLa11 q1>'L r, 7. Exact Location(s)of each Tank: lro� t 8/12/2021 STAtTr OF NEW YQRK,COUNTY OF WESTCHESTER ) as: �M1 et S r)QIJAy)2U 1) ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the apt ant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the for the legal owner and is duly authorized to make and file this application. (indicate 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 0-4-- day of ;J'u" ,20 day of )U,ny 20 Z ell, Signature of Property Owner Signature of Applicant / --T-1J o m A 5 KA\1At)R t)6 L-,—rn Prin of Property Owner Print Name of Applicant PATRICIA 0 RODRIGUEZ Notary Publ' LQualiffied ary u He- State of New York No Public NO. OIR06199133 in Westchester our mmission Expires 01)12J2'j. This application must be properly completed in its entirety and must include the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety and/or not properly signed shall be deemed null and void and will be returned to the applicant. @ .`IQANI`�LY°iVO4OLm-SANTC13 r� WWV POW10,sto of rMnecdcut M'V 27,2ID26 2 8/12/2021 NE'WYORK Department of STATE Of OPPORTUNITY Environmental Conservation Spill Incidents Database Search Details Spill Record Administrative Information DEC Region: 3 Spill Number: 2303709 Spill Date/Time Spill Date: 07/21/2023 Spill Time: 09:23:00 AM Call Received Date: 08/01/2023 Call Received Time: 09:23:00 AM Location Spill Name: KAVANAUGH - UST Address: 90 WINDSOR ROAD City: RYE BROOK County: Westchester Spill Description Material Spilled Amount Spilled Resource Affected #2 fuel oil UNKNOWN Soil Cause: Equipment Failure Source: Private Dwelling Waterbody: Record Close Date Spill Closed: 08/03/2023 "Date Spill Closed" means the date the spill case was closed by the case manager in the Department of Environmental Conservation (the Department). The spill case was closed because either; a) the records and data submitted indicate that the necessary cleanup and removal actions have been completed and no further remedial activities are necessary, or b) the case was closed for administrative reasons (e.g., multiple reports of a single spill consolidated into a single spill number). The Department however reserves the right to require additional remedial work in relation to the spill, if in the future it determines that further action is necessary. If you have questions about this reported incident, please contact the Regional Office where the incident occurred. Return To Results Refine This Search 1AItV �, 4) S S 4WL;t S Clean, Preserve...Protect APO Environmental Specialists P f S �O July 31,2023 Mr. Dominic Falcone Westmore Fuel 86 North Water Street Greenwich, CT 06830 D E C Subject: Tank Removal, July 21,2023 AUG - 4 2023 Kavanagh Residence 90 Windsor Road — Rye Brook New York VILLAGE OF RYE BROOK BUILDI G [DEPARTMENT NYS-DEC Spill#2303709 Dear Mr. Falcone: On July 21, 2023, Gnviroslueld staff completed the removal of one underground 275-gallon fuel oil tank located at the subject property. The former location of the tank is shown in site photographs enclosed with this letter. 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 Envitoshield, Inc., a State of New York licensed waste transporter at Safety-Kleen Systems, Inc., 120 Forbes Avenue, New Haven, 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 cause for a fuel release. Evidence of holes were observed in the tank bottom. A soil sample was collected from the bottom of the excavation, in the area presumed to be most impacted, and submitted to a 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 #3070621 (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 HIC.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 31,2023 Kavanagh Residence 90 Windsor Road 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 and laboratory analysis, Enviroshield did find indication of the tank systems failure. Subsequently, the NYC-DEC was notified and assigned spill #2303709; however, no reported constituent exceeds the NYS-DEC CP-51 regulatory criteria. Sincerely, Envir ie Inc. chard Louis Vice President Enclosures cc: Rye Brook Building Department via email torlandoQrvebr_Tok= Permit#MP23-089 NYS-DEC#2303709 AAgomwo Site Photographs Enviroshield 275-gallon Underground Tank Removal—July 21, 2023 Kavanagh Residence, 90 Windsor Road, Rye Brook, New York 10573 5 i t X i, 1 . I r rt i r t 'x c *r I yt Phone 1 of 4. Former location of underground tank. Photo taken at initial site visit February 7, 2023. Fill and vent pipes visible. Site Photographs Enviroshield 275-gallon Underground Tank Removal—July 21, 2023 Kavanagh Residence,90 Windsor Road, Rye Brook, New York 10573 r -f a Photo 2 of 4. Underground tank excavated, exposed, and removed.July 21, 2023. S Site Photographs Enviroshield 275-gallon Underground Tank Removal—July 21, 2023 Kavanagh Residence, 90 Windsor Road, Rye Brook, New York 10573 � r -• ,-' .,yam ,•_4y ,.,_. R_,— Photo 3 of 4.Tank removed. Empty tank grave.July 21, 2023 Photo 4 of 4. Former underground tank location. Grave backfilled and area restored.July 21, 2023. SENOR Clean, Preserve. ..Protect Environmental Specialists �J BILL OF LADING DESCRIPTION: Check applicable waste ID: JC (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). D �7/ ate: oQ f Total Quantity: gallons Generator Name: Weslpure- FUe Site Address: q0 l l n w RCXz=j City: State: ��Zip: ' 057 Telephone: � '� W.O #: Generator/Agent for Signature: Transporter: Enviroshield, Inc., 250 Moffitt Stree , Str ord, CT 06615 203-380-5644 Connecticut: CT- W-49 • New Yor 095; Westchester County NY: WC-27310-H1 , Connecti ut H.I.C. 0582 Driver Signature: Destination/Facility: Tradebe Treatment a d R ycling of Bridgeport LLC 50 Cross Street Bridgeport, Connecticut 06610 All liquid,sludge sediment and rinse water was disImsed at Safety-Klcen Approval Code: Svstems,Inc., 120 Forbes Avenue,New I lavers,CT 06512 (SEE BACK FOR HAZARD/SAFETY/RESPONSE DETAILS) F:\Templates\Mist\Bill of Lading Liquid.docx P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www.enviroshield.com intot'ci;emiroshield.com 80 Lupes Drive Tel:(203)377-9984 Stratford,CT 06615 Fax:(203)377-9952 A-*rr e-mail:cetl@cetlabs.com CWRIII INNOWN1Al 181INC,INC. Client: Mr.Richard Louis Enviroshield,Inc. P.O.Box 1296 Stratford,CT 06615 Analytical Report CET# 3070621 Report Date:July 28,2023 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY PO Number:31059 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 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK.,NY SAMPLE SUMMARY The sample(s)were received at 11.1°C. This report contains analytical data associated with following samples only. Sample ID Laboratory ID Matrix Collection Date/Time Receipt Date Tank Grave 3070621-01 Soil 7/21/2023 12:00 07/24/2023 Analyte: Percent Solids ISM 2540 GI Analyst:SEY Matrix:Soil Datcrrimc Laboratory ID Client Sample ID Result RL Units Dilution Batch Prepared Analyzed Notes 3070621-01 Tank Grave 96 1.0 % I B3G2505 07/25/2023 07/252023 14:45 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 2 of 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY Client Sample ID Tank Grave Lab ID:3070621-01 Sernivolatile 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 Notc, Naphthalene ND 100 1 EPA3545A B3G2615 07/26/2023 07/28/2023 01:55 Acenaphthylene 210 100 1 EPA 3545A 133G2615 0726/2023 07/28/2023 01:55 Acenaphthene ND 100 1 EPA3545A B3G2615 07/26/2023 07/28/2023 01:55 Fluorene ND 100 1 EPA 3545A 63G2615 07/26/2023 07/28/2023 0155 Phenanthrene 520 100 1 EPA 3545A B3G2615 07/2612023 07128t2023 01:55 Anthracene 200 100 1 EPA 3545A B3G2615 07/26/2023 07/28/2023 01:55 Fluoranthene 1500 100 1 EPA 3545A B3G2615 07/26/2023 07/29/2023 01:55 Pyrene 1300 100 1 EPA3545A B3G2615 07/26✓2023 07/28/2023 01:55 Benzolslanthracene 710 100 1 EPA 3545A B3G2615 07/26/2023 07/28/2023 01:55 Chrysene 770 100 1 EPA 3545A B3G2615 07/26/2023 07/28/2023 01:55 Benzolblfluoranthene 950 100 1 EPA 3545A B3G2615 07/26/2023 07/28/2023 01:55 BenzolkJfluoranthene 400 100 1 EPA 3545A B3G2615 07/26/2023 07/28/2023 01:55 Benzolalpyrene 790 100 I EPA3545A B3G2615 07/2612023 07/28/2023 01:55 Indeno(1,2,3-cdJpyrene 460 100 1 EPA3545A B3G2615 07/26/2023 07/28/2023 01:55 Dibenzla,hlanthracene 140 100 1 EPA3545A B3G2615 07/26/2023 07/28/2023 01:55 Benzolg,h,ilperylene 580 100 1 EPA3545A B3G2615 07/26/2023 07/28/2023 01:55 Surrogate:Nilrobenzene-0 60.8% 30-130 63G2615 07/26/2023 0712812023 01:55 Surrogate:1-Fluorobiphenyl 82.3% 30-130 B3G2615 07/26/2023 07/28/2023 01:55 Surrogate:Terphenyl-dl4 86.2% 30-130 B3G2615 07/26/2023 0712812023 01:55 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 `oteN Methyl-t-Butyl Ether(MTBE) ND 4.3 164 EPA5035A-L B362514 07/25/2023 07/25/2023 11:53 Benzene ND 4.3 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 Toluene ND 4.3 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 Ethylbenzene ND 4.3 1.64 EPA5035A-L B3G2514 07/25/2023 07/25/2023 11:53 m+p Xylenes ND 8.6 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 o-Xylene ND 4.3 1.64 EPA5035A-L B3G2514 07/25/2023 07/25/2023 11:53 Isopropylbenzene ND 4.3 1.64 EPA5035A-L B3G2514 07/25/2023 07/25/2023 11:53 n-Propylbenzene ND 4.3 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 1,3,5-Tr'unethylbenzene ND 4.3 1.64 EPA5035A-L B3G2514 0725/2023 07/251202311:53 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615-Tel:203-377-9984-Fax:203-377-9952-www.cetiabs.com Page 3 of 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY Client Sample ID Tank Grave Lab ID:3070621-01 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 4.3 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 1,2,4-Trimethylbenzene ND 4.3 1.64 EPA5035A-L B3G2514 07/25/2023 07/25/2023 11:53 sec-Butylbenzene ND 4.3 1.64 EPA5035A-L B3G2514 07/25/2023 07/25/2023 11:53 4-Isopropyltoluene ND 4.3 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 n-Butylbenzene ND 4.3 1.64 EPA5035A-L B3G2514 07/25/2023 07/25/2023 11:53 Naphthalene ND 8.6 1.64 EPA 5035A-L B3G2514 07/25/2023 07/25/2023 11:53 Surrogate.-1,2-Dichloroethane-d4 99.5% 70-130 B3G2514 07/25/2023 0712512023 11:53 Surrogate:Toluene-d8 97.1% 70-130 B3G2514 07/25/2023 0712512023 11:53 Surrogate:4-Bromofluorobenzene 105% 70-130 B3G2514 07/25/2023 0712512023 11:53 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 4 of 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK-NY QUALITY CONTROL SECTION Batch B3G2514-EPA 8260C Result RL Spike Source %Rec RPD Analyte (ug/kg) (ug/kg) Level Result %Rec Limits RPD Limit Notes Blank(B3G2514-BLKI) Prepared:7/25/2023 Analyzed:7/25/2023 Methyl-t-Butyl Ether(MTBE) ND 2.5 Benzene ND 2.5 Toluene ND 2.5 Ethylbenzene ND 2.5 m+p Xylenes ND 5.0 o-Xylene ND 2.5 Isopropylbenzene ND 2.5 n-Propylbenzene ND 2.5 1,3,5-Trimethylbenzene ND 2.5 tent-Butylbenzene ND 2.5 1,2,4-Trimethylbenzene ND 2.5 sec-Butylbenzene ND 2.5 4-Isopropyholuene ND 2.5 n-Buylbenzene ND 2.5 Naphthalene ND 5.0 Surrogate:l,2-Dich/oroethune-d4 953 70-130 Surrogate:Toluene-& 795 70-130 Surrogate:4-BromofLtorobenzene 117 70-130 LCS(B3G2514-BSI) Prepared:7/25/2023 Analyzed:7/2512023 Methyl-t-Butyl Ether(MTBE) 52.8 2.5 50.000 106 70-130 Benzene 52.0 2.5 50.000 104 70-130 Toluene 54.7 2.5 50,000 109 70-130 Etylbenzene 51.1 2.5 50.000 102 70-130 m+p Xylenes 98.7 5.0 100.000 98.7 70-130 o-Xylene 48.2 2.5 50.000 96.4 70-130 lsopropylbenzene 50.8 2.5 50.000 102 70-130 n-Propylbenzene 49.3 2.5 50.000 98.6 70-130 1,3,5-Trimethylbenzene 47.4 2.5 50.000 94.8 70-130 text-Butylbenzene 49.4 2.5 50.000 98.8 70-130 1,2,4-Trimethylbenzene 48.4 2.5 50.000 96.9 70-130 sec-Butylbenzene 48.9 2.5 50.000 97.8 70-130 4-Isopropyholuene 49.4 2.5 50.000 98.8 70-130 n-Butylbenzene 49.4 2.5 50.000 98.8 70-130 Naphthalene 53.7 5.0 50.000 107 70-130 Surrogate:1.2-Diehloroethaned4 924 70-130 Surrogate:Toluene-d8 101 70-130 Surrogate:4-Bromofluorobmzene 114 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 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY Batch B3G2615-EPA 8270D Result RL Spike Source %Rec RPD Analyte (ug'ke) (ug/kg) Level Result %Rec Limits RP Limit Notes Blank(B3G2615-BLKI) Prepared:7/26/2023 Analyzed:7/27/2023 Naphthalene ND 100 Acenaphthylene ND 100 Acenaphthene ND 100 Fluorene ND 100 Phenanthrene ND 100 Anthracene ND 100 Fluoranthene ND 100 Pyrene ND 100 Benzo[a]anthracene ND 100 Chrysene ND 100 Benzo[b]fluoranthene ND 100 Benzo[k]fluoranthene ND 100 Benzo[a]pyrene ND 100 lndeno[1,2,3-cd]pyrene ND 100 Dibenz[a,h]anthracene ND 100 Benzo[g,h,i]perylene ND 100 Surrogate:Nitrobenzene-d5 56.9 30-130 Sunvgate 2-Fluorobiphenyl 83.1 30-130 Surrogate:Terphenyl-a`14 78.8 30-130 LCS(B3G2615-BSI) Prepared:7/26/2023 Analyzed:727/2023 Naphthalene 2030 100 4,000 000 50.7 40-140 Acenaphthylene 2460 100 4,000 000 61.4 40-140 Acenaphthene 2640 100 4,000.000 65.9 40-140 Fluorene 2790 100 4,000.000 69.7 40-140 Phenanthrene 2800 100 4,000.000 70.1 40-140 Anthraeene 2810 100 4,000.000 70.3 40-140 Fluoranthenc 3130 100 4,000.000 78.2 40-140 Pyrene 3110 100 4,000.000 77.7 40-140 Benzo[a]ar.thracene 2770 100 4,000.000 69.2 40-140 Chrysene 2980 100 4,000.000 74.5 40-140 Benzo[b]fluoranthene 2700 100 4,000.000 67.5 40-140 Benzo[k]fluoranthene 2990 100 4,000.000 746 40-140 Benzo[a]pyrene 2870 100 4,000.000 71.6 40-140 Indeno[1,2,3-cd]pyrene 2960 100 4,000.000 73.9 40-140 Dibenz[a,h]anthracene 3020 100 4,000.000 75.5 40-140 Benzo[g,h,i]perylene 3150 100 4,000.000 78.8 40-140 Surrogate.Nitrobenzene-d5 40.1 30-130 Surrogate:2-Fluorobiphenvi 73.0 30-130 Surrogate:Terpheayl-d 14 744 30-130 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 6 Of 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY T 80 Lupes Drive Tel:(203)377-9984 Stratford,CT 06615 COMPHIf fNVIRONMINIAI HIM.X Fax:(203)377-9952 email:cet l @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. Connecticut Laboratory Certification PH0116 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 7 of 11 CET A:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY 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 Timothy Fusco 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 40%. D-The RPD between the sample and the sample duplicate is high. Sample Homogeneity may be a problem. +- The Surrogate was diluted out. "C 1-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. '172-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 8 of 11 CET#:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY CERTIFICATIONS Cerliried Analyses included in this Report Anslyte Certlficatlens EPA 8260C in Sail Methyl-t-Butyl Ether(MTBE) CT,NY,PA Benzene CT,NY,PA Toluene CT,NY,PA Ethylbenzene CT,NY,PA m-p Xylencs CT,NY,PA o-Xylcnc CT,NY,PA Isopropylbcnzcnc CT,NY,PA n-Propylbcnzene CT,NY.PA 1,3,5-Trimc1hylbcnzcnc CT,NY,PA tcri-Butylbcnzcnc CT,NY,PA 1,2,4-Trimcthylbcnzcne CT,NY,PA sec-Butylbenzenc CT,NY,PA 4-1 sopropy[toluene CT,NY,PA n-Butylbenzcnc CT,NY,PA Naphthalene CT,NY,PA EPA 8270D in Soil Naphthalene CT,NY,PA Acenaphthylcnc CT,NY,PA Accnaphthcnc CT,NY,PA Fluorene CT,NY,PA Phcnanthrene CT,NY,PA Anthraccne CT,NY,PA Fluoranthcne CT,NY,PA Pyrenc CT,NY,PA 8cnzo[a)anthraccnc CT,NY,PA Chrysene CT,NY,PA Bcnzo[b)fluoranthcnc CT,NY,PA Bcnzo[kl0uoranthcnc CT,NY,PA Bcnzo[aJpyrcnc CT,NY,PA Indcno[1,2,3-cdlpyrcnc CT,NY,PA Dibcnz[a,hJanthracenc CT,NY,PA Bcnzo[S,h,i Jperylcnc CT,NY,PA SM 2540 C in Soll Percent Solids CT Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•www.cetlabs.com Page 9 Of 11 CET Al:3070621 Project:Kavanagh,90 Windsor Rd,Rye BrooK,NY Complete Environmental 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.cedabs.com Page 10 of 11 L L IO L L abed N 310N I I I l a •1N00 d0 k It= s j I � IL I { 3 O m r S I LL I c i � O C P A Q y ❑ O C , C I a lco (n al a i y m or < W co U U C N1 poiallu plow ; O cai x a a panloSSIO 1 C _ E a a1 d101 Cf � � � ® � ,S o Q O dl MCI 0. �iiFfifi $7C < 3L�t F- F"' d301051 oY! ❑ N W�I~ � U) uod NuoVd s G i seplopsad UL 3811❑ XOS❑ 980d O VVNd OLZB 2I 3 E rn J Isn 10 OLle I I 7{ ® J !E b_ Hd1310 A yy Q sus8°)BH M933 (A p C sopewwy osxe a r 9 N m ( 1 ion 10(Me Z a U O ¢ H 0 d ter++ caRoO rs)ws k -� c .ABO saa41 v 0 __ .LY •(60 U`eN yy (.. ll 61 h •I•eQ aWQS KI �C�;` QfN;��V NS� I a cc � w y m A C _ E E o ,� w w 09 f l Co it C" o a _+I j( w W W A a (D nl I � LL ¢ ¢ Q W t � O �� mcv I O � �, 0 Cin 3 � NN® in r Z 3 6p1� " o H D E A I a CL .m E L m a , a I C cl m � ti � ter, C C 9 c E °i E 'H QM j"i�'•,0 m O 00 W 0. >, m m m ki®CD it O w w m E L C O j rt < Z w z r t �4M a p cC � FQ- O> 1 z G ' Wo .s � w W 51 Table 1—NYSDEC CP-51 Regulatory Comparison to Soil Sample Result Client: Enviroshield,Inc. Project: Kavanagh,90 Windsor Rd,Rye Brook,NY Matrix: Soil Collect Dates: 7/21/2023 Thru 7/21/2023 Lab Number 3070621-01 Sampled Name Tank Grave Sampled Date 7/21/2023 NY Soil Parameter CAS Number Value Qual EPA 8260C dry) Meth -t-Butyl Ether(MTBE) 2634-04-4 NA <4.3 Benzene 71-43-2 60 0.3 Toluene 208-88-3 700 <4.3 Eth (benzene 100-41-4 1000 <4.3 m Xylenes XYLMP 260 <8.6 o-Xylene 95-47-6 260 0.3 isoprop (benzene 98-82-8 2300 <4.3 n-Pro (benzene 103-65-1 3900 0.3 1,3,5-Trimethylbenzene 108-67-8 8400 0.3 tert-Bu (benzene 98-06-6 5900 0.3 1,2,4-Trimeth (benzene 95-63-6 3600 0.3 sec-Butylbenzene 135-99-8 11000 <4.3 4-Isoprop toluene 99-87-6 10000 <4.3 n-Butylbenzene 104-51-8 120DO 0.3 Naphthalene 91-20-3 12000 <8.6 EPA 8270D (Lgft d Acenaphthene 83-32-9 20000 <1DO Acenaphth ene 208-96-8 100000 210 Anthracene 120-12 7 100000 200 Senzo(a)Anthracene 56-55-3 1000 710 Benz a rene 50-32-8 1000 790 Benzo(b)fluoranthene 205-99-2 1000 950 Benzo( h,i)pe lene 191-24-2 100000 S60 Benzo(k)fluoranthene 207-M9 BDO 400 Chrysene 218-01-9 1000 770 Dibenz[a,h anthracene 53-70-3 330 1 140 Fluoranthene 206-44-0 100000 MID Fluorene 86-73-7 30000 <100 Indeno 1,2,3-cd]pyrene 193-39-5 500 460 Phenanthrene 85-01-8 100000 520 Pyrene 129-00-0 200000 1300 Naphthalene 91-20-3 220DO <100 SM 2540 G (%) Percent Solids TS NA 96 Notes: Report Generated on:7/28/2023 5:13:00 PM Qualifiers: Exceeds C-51 Criteria Reported present but not exceeding CP-51 Criteria BUILDING DEPARTMENT VILLAGE OF RYE BROOK JUN - 9 2023 938 KING STRF.rr RN,F. BRooK•NN' 10573 (914)939-0668 VILLAGE OF RYE BROOK w,Nyw.ryebrook.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 USE ONLY PFRMIT - �/ 3-_-04? Approval Date: ,,.., . .,.�.�? Permit Fee: S o� P� Approval Signature: �; T _ Other: Disapproved: (Ices 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 4 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 1 1): 06e-1 3 - duo - -113 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. ***#*•A++aA*****+a+#*#*++*i*i#**##a#*#**++#+*#ai*#i*+***#*iai++**r**+r+*****#**3#*##brit*#**+**i#**Ri* Application dated,­�' ^t is herchy 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 tarik(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(4• Abandonment ( )/Above Ground ( )• Buried in Ground 6--r I. Address: c1b l�,. �Sa R�?-(� SBL: 2. Property Owner&Address: MR —TV40mAJ �CAu.?�n a.��,�. qo 1�•�So2 �� Phonc k: Cell#: email: — 3. Contractor&Address: �����2�-5� T�� CT�>�-t� QisX S►fw1'�oZ� lam. O�tit� Phone#: 35- '5641-t Cellµ: 4. Applicant. E,II e c-S�mt)­n (17- T S+eLzic �rr�i�b2a Lt 06,6 is Phonef+: 56x" Cell#: cmailf---r^, J�. e Enj14Z51�444,toIr, 5. Indicate Fuel Type: Fuel Oil(•4- L.P.Gas( )•Gasoline( )•Other( ): 6. Number and Capacity of each lank: \' -wn5 C\ bw D- ;r­ LG 7. Exact Location(s)of each Tank: C ;.Ye-� ��t' pL IrF.� ���JLwLy) 8112.2021 all 00 w e a 66 Ln W � W3 0, � � G., 3 � ►'' i � ►fir a0 `e � °� � O .il b�D E', s eA p Cf �y A o I �q x u � V V m Ln 66 :, v Q< C g o t a w � o 00 (� CL z 00OS)1 ( � o 0. ; w ►`� � � � � � Fr � , � W ZI ` 'ti � � O � s V ►-y C/� C1 H M a � W c7 v: Eva a `°� Z 1 00 (� M"'i ►� cam; ~ �' .a Q ., O GQ y �r �, OC1 L V M .0 1' 1^\, QJI' F•1 M�i/11 [j /Myy FS,y z z � v Q W Ky ✓ Z oL4 O po o r�W M 00 / , 6 Q W 5 N 4 0 O C7 A O ca a ,� ►� w z � � N'r v � : _ { 9�6194 �E BRC�v'r w � BUILDING DEPARTMENT BUILDING 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.or� - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS: `� DATE: '7)-2A PERMIT# ISSUED. L-2�ECT: BLOCK: LOT: LOCATION: `" '� ;OCCUPANCY: ❑ Violation Noted THE WORK IS... rASUED FAILED REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas ❑ L.P. Gas FUEL TANK ❑ FIRE SPRINKLER ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL l_�\ ,U \\ e �X� • " 1�C��C ❑ OTHER \ j b �XE,(- e• .P , �+%�{C. O Ft�hy"'ny fie 0,O5 ;i+' ,�4�* v st6' '0� RROY •A '�+{ ,$'• tO�[ ,`• 7O , , 0....i 00,1�S.: 'c��j-0` i v f�1i r q •i r i r v Ski.. • N .' v ♦f l� -7y,"' ..k+�1��`�+ ,�►(•�4�,;•� $"��`�t�' ;r�,,���f�,���� �� �;�ri[5�,�.:qt i�'t i: � ,� �M0i+�7';���k ,y�if��,�fi/y {y��,•;i+� �,•. �� `�' i �"- 'Rn� �ti=�'+1l ����',t=�-;..t�'Yis��`+�� ++�jr�;•, .��-=:�t,�,,t�+.ris°f -�1::.��1���tS:Y��=3�SA_��+i r�(f+:;=>���s4ti.'3Jc+�+1,�r:�$y'j.,�:.�,, e. •a8t7++ .cr'7.�; A. O h EL 64 � 04 c C V •s : O • R y C 4.. !•fa`i `tea I \ 't'1 Y O •U /f�Y S �y I Q W to 0 t1 z W o ° a sectionFL u cai] c `�` t) icy ' •� to � y O d "gyp a �e9 �•a. r.�i� ,1 N c :L) C00 � 3 - AC3 C3 :. i +• cu cn 6�1 L N U � •� �;' r .. r '... r ..�r �' .:rr •,ivy r �� ��w�'. —�� ENVIINC-01 MTOMASELLI ACORO'• CERTIFICATE OF LIABILITY INSURANCE DATE(Mks DD/YYYY) 5/20//2023 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 HAo4�ACT Mary Tomaselli GOWrie Group PHONE FAX 70 Essex Road (A/C,No.E�:.- --- ---._ _..._ _ _jAIC.No): _ Westbrook,CT 06498 A p%6timtom �risk-Strata9aselll ies com ---� INSURERS)AFFORDING COVERAGE NAIC 0 _ _INSURER A:Nautilus Insurance Company_ ___ 17370 INSURED INSURER a:Great Divide Insurance Company 2§224 Enviroshield Inc.and E.G.Kost Rental,LLC INSURERC: PO Box 1296 ---- --- 250 Moffitt Street rINSURERD: Stratford,CT 06615 INSURER E_. 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 CONTRACT OR 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 TYPE OF INSURANCE IADDL'SUB POLICY NUMBER i POLICY EFF I POLICY EXP LIMITS MWDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I S_ 1'000,000 CLAIMS-MADE L^u OCCUR ECP01521982-23 12/1/2022 12/112023 DAMAGE TO R nilip9 S _100,000 X Pollution Liability MED EXP tAm one person_TONAL S ADV INJURY S 5,000 —X-1 Professional Llab P 1,000,000 S GENLAGGREGATE pLRIM�IT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY I n�JECT LOC PRODUCTS-COMP/OP AGG S 2,000,000 ' OTHER' B j AUTOMOBILE LIABLITY COMBWEOSINGLE LIMIT 1.000,000 lPaLatxieanl-- ANY AUTO BAP1521979-23 12/1/2022 l 12/1/2023 B_ODILYNJURY-(P person) $ OWNED X SCHEDULED i AUTOS ONLY ONLY AUTOS BODILY NJURY(Per accWenU.S X AUTOS ONLY X I OPEpAMACE — X MCS-90 End1 A UMBRELLA LW X OCCUR EACH OCCURRENCE S 1,000.000 X EXCESS LW CLAIMS-MADE FFX 2036752 11 12/112022 12/1/2023 AGGREGATE S 1,000,000 DED I X !RETENTIONS 10,000 B WORKERS COMPENSATION X PER I OTH- AND EMPLOYERS'LIABILITY 1 STATDTE.1 �Y.li�t WCA 1521980 22 12/1/2022 12/112023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE F.l�. ACCIDENT $ �FFICER/MEM8ER EXCLUDED? NSA 1,000,000 itandatory in NH) E.L DISEASE-EA EMPLO __ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMB i DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) 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 938 King Street y „( �BYe @19olt`NY_t453_3— --- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. TheACORD name and logo are registered marks of ACORD . t STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.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 ifcoverage 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"la" WCA 1521980 22 Village of Rye Brook 938 King Street 3c. Policy effective period Rye Brook,NY 10573 12/1/22 to 12/1/23 3d. The Proprietor,Partners or Executive Officers are ■included. (Only check box if all partners/officcrs 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"T'. 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 maybe 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.Falcigno (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.0 dig ny.org> Sent: Wednesday,June 7, 2023 9:45 AM To: Steven Fews Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 06/07/2023 09:44 To: VIL RYE BROOK PRIMARY Transmitted: 06/07/2023 09:44 00002 Ticket: 06073-000-733-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: PORT CHESTER Addr: From: 90 To: Name: WINDSOR RD Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: FRONT RIGHT OF HOUSE NearSt: RIDGE BLVD 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: 07/07/2023 Depth of excavation: 8 FEET Site dimensions: Length 10 FEET Width 6 FEET Start Date and Time: 06/12/2023 07:00 Must Start By: 06/27/2023 ------------------------------------------------------------------------------ Contact Name: PAULA ARCURI Company: ENVIROSHIELD Addr1: 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: WESTMORE FUEL ------------------------------------------------------------------------------ Comments: Lookup Type: ADDRESS ------------------------------------------------------------------------------ Members: ALTICE USA BELL-VALHALLA/ WSCHSTR CONED SUEZ WTR WESTCHESTER VIL PORT CHESTER VIL RYE BROOK WESTCHESTER CTY SWR i Laura Petersen From: UDig NY Exactix <tickets@exactix.udigny.org> Sent: Thursday,July 6, 2023 11:10 AM To: Steven Fews Subject: Message from UDig NY ****REGULAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 07/06/2023 11:09 To: VIL RYE BROOK PRIMARY Transmitted: 07/06/2023 11:09 00003 Ticket: 07063-000-936-00 Type: Regular Previous Ticket: 06073-000-733-01 ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: PORT CHESTER Addr: From: 90 To: Name: WINDSOR RD Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: FRONT RIGHT OF HOUSE NearSt: RIDGE BLVD 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: 07/28/2023 Depth of excavation: 8 FEET Site dimensions: Length 10 FEET Width 6 FEET Start Date and Time: 07/20/2023 07:00 Must Start By: 08/03/2023 ------------------------------------------------------------------------------ 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: WESTMORE FUEL ------------------------------------------------------------------------------ Comments: Lookup Type: ADDRESS ------------------------------------------------------------------------------ Members: ALTICE USA BELL-VALHALLA/WSCHSTR CONED SUEZ WTR WESTCHESTER VIL PORT CHESTER VIL RYE BROOK WESTCHESTER CTY SWR i