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HomeMy WebLinkAboutMP24-010 DRY O ECG j V J�1. 1/ L G VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.ryebrook.org TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE March 7,2024 Alfred Covino&Margaret Covino 18 Churchill Road Rye Brook,New York 10573 Re: 18 Churchill Road, Rye Brook,New York 10573 Parcel ID#: 135.26-1-25 As per the Certification letter from Enviroshield Inc dated February 28,2024,the removal of an underground oil tank under Mechanical Permit#24-010 issued on 1/30/2024 has been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to QyE BRC��, cu � 1982 BUILDING DEPARTMENT ❑$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 - - - - - - - - - - - - - - - - - - - - ADDRESS :- C ' ` VA f C^ t 1 � \ --)(, DATE: 2 z PERMIT# m \ Z '/ - 0 1 O ISSUED: V'Z SECT: Z(o BLOCK: LOT: Z 5 LOCATION: C P J i CZ G t }\ Ar OCCUPANCY: ❑ Violation Noted THE WORK IS... 0 PASSED ❑ FAILED /REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION ❑ Natural Gas G A L.L o j LEI , S . / ❑ L.P. Gas 4 y/11 A l L 1r✓J 21C �'�.� P (p c� G✓, [[FUEL TANK -SST ❑ FIRE SPRINKLER S S t/� i 4 r C UJ� cJ HIC e\✓�° ❑ FINAL PLUMBING ❑ OS CROSS CONNECTION �. I � IZ ` tl2 r'l r N ✓12 (�S `� I �' L a r ❑ FINAL ❑ OTHER ,. .� 1 � v r. • w1t ti• � / J �a t \`,.� r'Via.•�� .. - � 1 '�t '�, `• •'�� � ,n Od y tir t�' .'z•; _ S N y = 0 W g m m C) _ � N N ,w• •��j s cq A a •� 9. Y y m Hr' W a w H Le) N a O cn ap v 'b m O ~ C u u y m OLO C1+ y A cu 0 1.4 a ■ O.J 0.0 � 5 ►'7. w Q w 5 o Mo0oc � w o z U Z v ti o COD to to a ego V A y � Q o a v � � cn a>, E a W o � v o u v Q' z z � F� 64 a o ~ Q W. Q oo � �o U p o v 1-4 a V can w H O O �• °� �; r+i O C) V V av� c° w O A 0 �" .4 QUO Z W `n E� od �' o � •• A p V U W � � �v - � _ 0 vi � "� � =d BUILt :� MENT C� VILOF RY OOK 938 KING RYE BR off,NY 10573 JAN 2 4 2024 -0 8 r, VILLAGE OF RYE BROOK 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 OFFICE USE ONLY: PERMIT #: H'A'DZI— D )o Approval Date: J AN kr3) �24 Permit Fee: $ 1C3 15 _/0,Z) Approval Signature: Other: Disapproved: (fees are non-refundable} **iF#ah**k*ak**•leIt*#iF,t7kik**Ir*4r*t*ir�rAr*******tM*,t**e+r*rF********9rrY*��****�**;r: :r*****!t#**Jk**#*tr****at*icir+�:***�**�:F:� DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 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): 0 t I G - C7 n e - 147,1„-Q O 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, ,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 X. Abandonment( )1 Above Ground ( )•Buried in Ground l. Address: k 1,Cre t O Ct J SBL: I35i c) �)Y Zone: -I 5 2. Property Owner&Address: 04 at- t7,.,.r c-t- (_ n VIA n- 1!!Z eAu i'G k III - mil: ropy Phone#: r1 1 �13 -G((n Cell#: I� 3�;7 a Sf I email-ryti� �. C� y►r,0 6�ll'-�. , AC'+- 3. Contractor&Address: l vt o G ;nn -wo I6- Phone#: oZ0,3-7j�(�_ �� Cell#: email: I rn M FYI V1(-nil,i f'�i Y, 0_0 m 4. Applicant: ofxc&rd Chl Phone#: -`J O--J)A Cell#: email: 1 () - E'at✓I r A * Co M 5. Indicate Fuel Type:Fuel Oil •L.P.Gas( ) •Gasoline( )•Other( ): at- ;am, G 0 I 6. Number and Capacity of each Tank: [���_ ��J� 10 Q C) T Exact Location(s)of each Tank: U0I t 10/30/2023 STAVE OF NEW YORK, COUNTY OF WESTCHESTER ) as: L,ev\ 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 Z.,gor 0 5huy t OL. I r G 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 cI 01 Sworn to efore me this day of ah t_� 20 a� day of 1 .41 , 120 j w 17,&a �— — gna of Pro erty Owner Si ature o Applicant Pr' Pr wrier rin m c SCOTT J.GQWE Notary Public NOTARY PUBLIC OF NEW YORK Notary Pub is I D #01 G063571 S / SCOTT J.GOWE MY COMMISSION EXPIRES 1�722 NOTARY PUBLIC OF'NEWWYORK I.D.0 01GO63571 P MY COMMISSION EXPIRES'�1�lr 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. a+,�.a' DANIELLY NOV'OLI-SANTOS t Wary Public,State ul Connecticut My Commission Expires May 27,2026 z 10/30/2023 i. i t V �-- i '+, Fri' .�� L� ��� � � � � � � � a � � � S v � � q �1E. L � � � � S S L ,.. ` ` � � 1J S T � ti D E Clean, Preserve...Protect �i►�'O�` MAR 1 2024 Environmental Specialists - ( S VILLAGE OF RYE BROOK BUILDING_DEPARTMENT February 28, 2024 Alfred and Margaret Covino 18 Churchill Road Rye Brook,NY 10573 Subject: Tank Removal, February 22,2024 Residence 18 Churchill Road Rye Brook,IVY Permit# MP24-010 Dear Mr. and Mrs. Covino: On February 22, 2024, Enviroshield staff completed the removal of one (1) 550-gallon underground fuel oil tank located at the subject property. The former location of the tank and progression of the tank removal process is shown in the 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 a licensed waste disposal/recycling facility. Attached is a copy of the liquid waste transport Bill of Lading.The tank was found to be partially filled with oil impacted sand. The contents were removed and disposed of at Clean Earth of Carteret.Clean Earth is a licensed soil disposal/recycling facility located in Carteret New Jersey. The waste disposal manifest is also included. 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 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 the 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(CE1)report#24130573,the reported results for the sample tested are below the laboratory detection limit for all the constituents tested;no petroleum was detected within the sample. CT Home Improvement Contractor HIC.0582591 —Westchester Home Improvement License WC-27310-1114 250 Moffitt Street, Stratford, CT 06615 (203) 380-5644 FAX(203) 378-8736 www.enviroshield.com- info@enviroshield.com Page 2of2 February 28,2024 18 Churchill Road Rye Brook,NY 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 any of this work, please do not hesitate to contact me at your earliest convenience at (203) 380-5644. SiA&viro l . Vice President Enclosures cc: Village of Rye Brook Building Department(lpetersen(Qrvebrook.orv) Clean, Preserve...Protect Environmental Specialists Site Photograph 1 of 4 18 Churchill Road Rye Brook, NY 10573 Former location of the underground tank r i• p F i r P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www.enviroshield.com info c,enviroshield.com Q. Clean, Preserve...Protect Environmental Specialists Site Photograph 2of4 18 Churchill Road Rye Brook, NY 10573 Image of buried tank filled with sand r, rl - t. 'i s P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www.enviroshield.com info 0enviroshield.com Clean, Preserve...Protect Environmental Specialists Site Photograph 3of4 18 Churchill Road Rye Brook, NY 10573 Image of the excavation after tank removal . .c•tl� ._Jr " + u Fv • P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www.enviroshield.com infoRenviroshield.com Clean, Preserve...Protect Environmental Specialists Site Photograph 4of4 18 Churchill Road Rye Brook, NY 10573 Image of former location of the tank after backfilling N r 4 f1 • � I fi y P.O.Box 1296.250 Moffitt St., Stratford,CT 06615 (203)380-5644 (800)394-2268 FAX(203)378-8736 www.enviroshield.com inf a,enviroshield.com Clean, Preserve.. .Protect C, Environmental Specialists BILL OF LADING DESCRIPTION: Check applicable waste ID (NA1993) Fuel oil !diesel f 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: ?,Z 2 Total Quantity: gallons 1 Generator Name: A 1 CL rq e-✓ -,!+ Site Address: 1 q C' � c" ` 4i ` ( a _J City: 1— �� � Stater zip: � q/L/' �3 I? - (i/(1J Telephone: "'W.O it: Generator/Agent for Signature: Q�:� Transporter: Enviroshield, Inc., 250 Moffitt Street, Stratford, CT 06615 203-380-5644 7 Connecticut: CT-HW-495; New York: CT-095; We ester County NY: WC-27310-H14; Connecticut H.I.C. 0582591 Driver Signature: Destination/Facility: Tradebe Treatment and Recycling of Bridgeport, 50 Cross Street, Bridgeport, CT 06610 Safety-Kleen Systems, Inc., 120 Forbes Avenue, New Haven,CT 06512 Approval Code: (SEE BACK FOR HAZARD/SAFETY/RESPONSE DETAILS) F:\TemplatesWisc\BIII 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 info(@enviroshield.com CleanEarth"o Manifest GLOBALJOB NUMBER: 1017233 FACILITY 243070277 Please Check One: Clean Earth of Carteret i_1 Clean Earth of Maryland ❑Clean Earth of Now Castle ❑Clean Earth of Greater washinglon 24 Middlesex Avenue 1469 Oak Ridge Place 94 J Caldwell Lane 6250 Dower House Road Carteret•NJ 07008 Hagerstown,MD 21740 New Casbe,DE 19720 Upper Marlboro,ME)20772 Ph:732.541.8909 Ph:301-791-6220 Ph:302427-6633 Ph:301-599-0939 ❑Clean Earth of Philadelphia 0 Clean Earth of North Jersey Cl Clean Earth of Southeast Pennsylvania ❑other 3201 S.61st Street 115 Jacobus Avenue 7 Sisal Road East Phlladelphra,PA 19153 Kearny,NJ 07032 Morrtsvfle,PA 19067 Ph:215-724-5520 Ph:973-344-4004 Ph:215-428-1700 _. Non-Hazardous Material Manifest LTYee_or Print Clearly GENERATOR'S NAME& SITE ADDRESS: GROSS wEiol-rr: i- -- -m.c: ;•tra ;-4uvst�o --—- Ions ❑Yards -- - r TARE WEIGHT: Port r nri7l, ❑Tons ❑Yards GENERATOR'S PHONE: NET WEIGHT: - ❑Tons []Yards DESCRIPTION OF MATERIAL/SAh1PLE ID AND LOCATION Pick up Material at 250 Moffitt Street Stratford CT . S;�r<IYE VD0H'S CLK'f1F1CA'1'[ON - Incomplete and/or unsigned manifests will cause the load to be delayed and/or rejected. [hereby certify that the hove n•med materi does not contain free liquid as defined by 40 CFR Part 260.10 or any applicable state law,is not a haiardou. waste dcti ed h 0 CFR Part 261 or any applicable state law,is not a DOT hazardous substance as defined by 49 CFR Part 172 sy lica le s law, has been fully and accurately described above.classified,p c ged and is in proper condition for tran ii t c r ing 11 appli ble state and federal regulations,Name: Title: Title: ! l Signature: ✓ q, - Date and Time: _ aliaut Contra trag,LLt: 225 Prospect Poi.Rt Road, 1373 -234-5668 Company: Phone!dumber: it Address: y A� Truck 0 and License Plate: ZVI .glz)6 Driver: /j� SW Haulers Permit 4: (Type r Piing Cleurly) (applicable state perrniO) a certify the Bove named material was picked up at the site listed above. Driver Signature: Date and Time: DESTINATION I hereby rt ah, moil mate ' was delivered without incident to the facility noted above. Driver Signatw•e: _ r Date and rime: 1 hereby certify t tat t u uve named material has been accepted at the ab a referenced facility. Authorized Signature: �—, Date and Time: 1�4C;IJi'i 80 Lupes Drive Tel:(203)377-9984 Stratford,CT 06615 Fax:(203)377-9952 e-mail:cetl@cetlabs.com COMRIII INVIROWN111111ISiINC,X Client: Mr.Richard Louis Enviroshield,Inc. P.O.Box 1296 Stratford,CT 06615 Analytical Report CET# 24BO573 Report Date:February 29,2024 Project: Covino, 18 Churchill Rd,Rye Brook,NY PO Number:31327 Connecticut Laboratory Certificate:PH 01 16 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#:24BO573 Project:Covino,18 Churchill Rd,Rye Brook,NY SAMPLE SUMMARY The sample(s)were received at 2.2°C. This report contains analytical data associated with following samples only. Sample ID Laboratory ID Matrix Collection Date/Time Receipt Date Tank Grave 24BO573-01 Soil 2/22/2024 11:00 02/23/2024 Analyte: Percent Solids [SM 2540 G] Analyst:H Matrix: Soil Date/Time Laboratory ID Client Sample 1D Result RL units Dilution Batch Prepared Analyzed Notes 24B0573-01 Tank Grave 84 1.0 111. 1 BB42331 02/23/2024 02/23/2024 16:37 Complete Environmental Testing,Inc. 80 Lupes Drivc,Stratford,CT 06615-Tel:203-377-9984-Fax:203-377-9952-www.cetlabs.com Page 2 of 12 CET N:24BO573 Project:Covino,18 Churchill Rd,Rye Brook,NY Client Sample ID Tank Grave Lab ID:24BO573-01 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 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Accnaphthylene ND 120 1 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Acenaphthene ND 120 1 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Fluorene ND 120 1 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Phenanthrene ND 120 1 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Anthracenc ND 120 1 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Fluoranthene ND 120 1 EPA 3545A BB42336 02/27/2024 02/28/2024 14:46 Pyrene ND 120 1 EPA 3545A B342336 02/27/2024 02/28/2024 14:46 Benzo[a]anthtacene ND 120 1 EPA 3545A BB42336 02/27/2024 0228/2024 14:46 Chryscnc ND 120 1 EPA 3545A B342336 02/27/2024 0228/2024 14:46 Benzo[b]fluorantbene ND 120 1 EPA 3545A BB42336 0227/2024 0228/2024 14:46 Benzo[k]fluoranthcnc ND 120 I EPA 3545A BB42336 0227/2024 0228/2024 14:46 Benzo[a]pyrene ND 120 1 EPA 3545A BB42336 02/27/2024 0228/2024 14:46 Indcno[1,2,3-cd]pyrcnc ND 120 1 EPA 3545A BB42336 02272024 02282024 14:46 Dibenz[a,h]anthracene ND 120 1 EPA 3545A BB42336 0227/2024 02292024 14:46 Benzo[g,h,i]perylene ND 120 1 EPA 3545A BB42336 02272024 0228/2024 14:46 Surrogate:Nitrobenzene-d5 55.2% 30-130 BB42336 02/27/2024 0212812024 14:46 Surrogate:1-Fluornbiphenyl 64.2% 30-130 BB42336 0227/2024 0212812024/4:46 Surrogate:TerphenyW74 87.1% 30-130 BB42336 02/272024 0212812024 14:46 Volatile Organics Analyst: MR Method: EPA 8260C Matrix: Soil Result RL Date/Time Analyte (ug/kg dry) (uglkg dry) Dilution Prep Method Batch Prepared Analyzed Notes Methyl-t-Butyl Ether(MTBE) ND 4.7 1.59 EPA 5035A-L BB42324 02/232024 02/23/2024 14:48 Benzene ND 4.7 1.59 EPA 5035A-L BB42324 02/232024 02232024 14:48 Toluene ND 4.7 1.59 EPA 5035A-L BB42324 02/232024 0223/2024 14:48 Ethylbcnzcnc ND 4.7 1.59 EPA 5035A-L BB42324 02/232024 02/232024 14:48 m+p Xylenes ND 9.4 1.59 EPA 5035A-L BB42324 0223/2024 02/232024 14:48 o-Xylene ND 4.7 1.59 EPA 5035A-L BB42324 0223/2024 02/23/2024 14:48 Isopropylbenzene ND 4.7 1.59 EPA 5035A-L BB42324 02/23/2024 02/23/2024 14:49 n-Propylbenzene ND 4.7 1.59 EPA 5035A-L BB42324 0223/2024 02232024 14:48 1,3,5-Trimethylbenzene ND 4.7 1.59 EPA 5035A-L BB42324 0223/2024 02/232024 14:48 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 N:24BO573 Project:Covino,18 Churchill Rd,Rye Brook,NY Client Sample ID Tank Grave Lab]ED: 24BO573-01 Volatile Organics Analyst:MH Method:EPA 8260C Matrix: Soil Result RL Date/Time Analyte (ug/kg dry) (ug/kg dry) Dilution Prep Method Batch Prcpared Analyzed Notes tert-Butylbenzene ND 4.7 1.59 EPA 5035A-L BB42324 02/23/2024 02/23/2024 14:48 1,2,4-Trimethylbenzene ND 4.7 1.59 EPA 5035A-L BB42324 02/23/2024 02/23/2024 14:48 sec-Butylbenzene ND 4.7 1.59 EPA 5035A-L BB42324 0223/2024 02/23/2024 14:48 4-1sopropyltoluene ND 4.7 1.59 EPA 5035A-L BB42324 02/232024 0223/2024 14:48 n-Butylbenzene ND 4.7 1.59 EPA 5035A-L B1342324 02/23/2024 0223/2024 14:48 Naphthalene ND 9.4 1.59 EPA 5035A-L BB42324 02/23/2024 02/23/2024 14:48 Surrogate:1,1-Dichluruethane-d4 93.4% 70-130 BB42324 0223/2024 0212312024 14:48 Surrogate:Toluene-d8 99.6% 70-130 BB42324 02/23/2024 0212312024 14:48 Surrogate:4-BromoJluorobenrene 103% 70-130 BB42324 0223/2024 0212312024 14:48 Complete Enviromnental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615-Tel:203-377-9984-Fax:203-377-9952•wHrv.cetlabs.com Page 4 of 12 CET#:24BO573 Project:Covino,18 Churchill Rd,Rye Brook,NY QUALITY CONTROL SECTION Batch BB42324-EPA 8260C Result RL Spike Source. "/Rec RPD Analyte (ug/kg) (ug/kg) Level Result %Rec Limits RPD Limit Notes Blank(BB42324-BLKI) Prepared:2/23/2024 Analyzed:2/232024 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 N D 2.5 1,3,5-Trimethylbenzene 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-Butylbenzene ND 2.5 Naphthalene ND 5.0 Surrogme:1.2-Dichloroethane-d4 91.2 70-130 Surrogate:Toluene-& 995 70-130 Surrogate:4-Bromoffuorobenzene 103 70-130 LCS(BB42324-BS1) Prepared:2/232024 Analyzed:2232024 Methyl-t-Butyl Ether(MTBE) 55.7 2.5 50.000 111 70-130 Benzene 58.9 2.5 50.000 118 70-130 Toluene 58.0 2.5 50.000 116 70-130 Ethylbenzene 55.2 2.5 50.000 110 70-130 m+p Xylenes 112 5.0 100.000 112 70-130 o-Xylenc 55.6 2.5 50.000 111 70-130 Isopropylbcnzcnc 55.7 2.5 50.000 111 70-130 n-Propylbenzene 53.5 2.5 50.000 107 70-130 1,3,5-Trimethylbenzene 54.2 2.5 50.000 108 70-130 tert-Butylbenzene 54.2 2.5 50.000 108 70-130 1,2,4-Trimethylbcnzene 54.2 2.5 50.000 lox 70-130 sec-Butylbenzene 54.4 2.5 50.000 109 70-130 4-Isopropyltolucnc 54.7 2.5 50.000 109 70-130 n-Butylbenzene 54.3 2.5 50.000 109 70-130 Naphthalene 55.4 5.0 50.000 ill 70-130 Sum,gate:1.2-Dichluroethane-d4 91.2 70-130 Surrogate:Toluene-d8 99.2 70-130 Surrogate:4-Bromofluombenzene 102 70-130 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615•Tel:203-377-9984•Fax:203-377-9952•ww w.cetlabs.com Page 5 of 12 CET#:24B0573 Project:Covino,18 Churchill Rd,Rye Brook,NY Batch BB42336-EPA 8270D Result RL Spike Source %Rec RPD Analyte (ug/kg) (ug/kg) Level Result %Rec Limits RPD Limit Notes Blank(BB42336-BLKI) Prepared:2/27/2024 Analyzed:2/28/2024 Naphthalene ND 100 Acenaphihylene ND 100 Acenapbthene ND 100 Fluorene ND 100 Phenanthrene ND 100 Anthracene ND 100 Fluoranthenc 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 Sunrrgare:Nitrobercene-d5 59.5 30-130 Su ,gale:2-Fluarobiphenvl 71.1 30-130 Surrogate:Terpbenyl-d14 68.0 30-130 LCS(BB42336-BSI) Prepared:2/27/2024 Analyzed:2/28/2024 Naphthalene 2690 100 4,000.000 67.2 40-140 Acenaphthylene 3040 100 4,000.000 76.0 40-140 Acenaphthene 3220 100 4,000.000 80.5 40-140 Fluorene 3160 100 4,000.000 79.0 40-140 Phenanthrene 3210 100 4,000.000 80.2 40-140 Anthracene 3190 100 4,000.000 79.9 40-140 Fluoranthene 3240 100 4,000.000 81.0 40-140 Pyrene 3280 100 4,000.000 82.1 40-140 Benzo[alandmcene 3110 100 4,000.000 77.8 40-140 Chrysene 3180 100 4,000.000 79.6 40-140 Bcnzo[b]fluoranthcnc 3150 100 4,000.000 78.7 40-140 Benzo[k]fluoranthene 3300 100 4,000.000 82.6 40-140 Benzo[a]pyrene 3130 100 4,000.000 78.2 40-140 lndeno[1,2,3-cd]pyrene 3190 100 4,000.000 79.9 40-140 Dibenz[a,h]anthracene 3120 100 4,000.000 77.9 40-140 Benzo[g,h,i]perylene 3440 ]on 4,000.000 86.0 40-140 Surrogate.Nitrobenzene-6 790 30-130 Surrogare:2-Fluwabiphenyl 90.7 30-130 Sum,guie:Terphenyl-d14 103 30-130 Complete Environmental Testing,Inc. 80 Lupes Drive,Stratford,CT 06615-Tel:203-377-9984•Fax:203-377-9952-www.ectlabs.com Page 6 of 12 7] CET#:24B0573 Project:Covino,18 Churchill Rd,Rye Brook,NY 80 Lupes Drive It" Tel:(203)377-9984 Stratford,CT 06615 COMRfff INVIAONMINTAI11 STING,INE Fax:(203)377-9952 email:cell@cetlabs.com Quality Control Definitions and Abbreviations Internal Standard(1S) 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 dhe 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 12 CET ti:24BO573 Project:Covino,18 Churchill 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 Jeffrey Smith '14 '0�4 ///a. J, 'G�� 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. *CI-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 8 of 12 CET#:24B0573 Project:Covino,18 Churchill Rd,Rye Brook,NY CERTIFICATIONS Certified Analyses included in this Report Aaalyte Certifications EPA 8260C in Soil Mcthyl-t-Butyl Ether(MTBE) CTNY,PA Benzene CTNY,PA Toluene CTNY,PA Ethylbenzene CTNY,PA nt+p Xylenes CTNY,PA o-Xylene CT,NY,PA Isopropylbenzene CTNY,PA n-Propylbenzcnc CTN Y,PA 1,3,5-Trimethylbenzene CTNY,PA tert-Butylbenzene CTNY,PA 1,2,4-Trimethylbcnzene CT,N Y,PA sec-Butylbenzene CTNY,PA 4-Isopropyltoluene CTNY,PA a-Butylbenzene CT,NY,PA Naphthaicnc CT.NY,PA EPA 8270D In Soil Naphthalene CT.NY,PA Acenaphibylene CT.NY,PA Accnaphthcnc CTNY,PA Fluorene, CT.NY.PA Phenanthrene CT.NY,PA Antbraccnc CT,NY,PA Fluoranthene CT,NY,PA Pyrene CTNY,PA Benzo[a)anthracenc CTNY,PA Chrysene CTNY,PA Beuzo[b]tluoranthcoc CTNY,PA Bewo[k]fluomathene CT.NY,PA Benzo[a]pyrenc CTNY,PA Indeno[l,2,3-cd]pyrene CTNY,PA Dibenz[a,h]anthracene CTNY,PA Benzo[g,h,ilperylene CT,NY,PA SM 2540 G in Soil 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 12 CET#:24BO573 Project:Covino,18 Churchill Rd,Rye Brook,NY Complete Environmental Testing operates under the following certifications and accreditations: Code Description Number Expires CT Connecticut Public Healtb PHO116 09/30/2024 NY New York Certification(NELAC) 11982 04/01/2024 PA Pennsylvania DEP 6M2927 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 10 of 12 T p 31ONER7 � O 1N07 J0 01V1a1 .: N m ¢ Q) cz a_ O c a En c con m � Q o r as m W yam • � > PajelN.1 M914 E _ z d o PQAtMja o co0 . 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(U o v v Id 0 E owl4 Ho +bj) I,, A"• O a F— L o o lu 010 � 3 rA - � O � f•Y � � � l O � ¢ b �b ate' � M Oo�zp0 o w U " ° ° Uz ° u o p 4ii z 5i y q AO•� a I~ ~ 00 � W. 5 aq " � � � ¢ x � x w g , z � a w a O W z a 0 Nib ° 0M-4 E" w z z o a °' - L U o ao .5y a V w o U o ° a� � �v k M� Q O ►n o 000 V U U O 60- F" A O Q � R, U °' � BUILDING.D)EPARTMENT D �- VILLAGE of RY�c,IiROOK JAN 2 4 2024 938 KING S-i-It"E'r RYE BROO-K,NY 10573 VILLAGE OF f:'rE 6ROOK I www.ry roolcorg BUILDING DEPA RTIJIENT Application for Permit to Remove, Abandon and/or Install Fuel Storaee Tank (*Storage Tanks in excess of 1,100 gallons require registration with the County of Westchester) FOR OFFICE USE ONLY: PERMIT#: HAQ4— Do Approval Date: ,AN 30 624 Permit Fee: S Y ,P I Approval Signature: _ Other: Disapproved: (fees arc non-refundable) DO NOT START WORK or CONSTRUCTION UNTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR.THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITII A MINIMUM FEE OF$750.00 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 ol'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 Safely New York#(dial 81 1): O t I C1 - r)n b - q 7 a -O O 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, 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 confonnancc with all applicable Village,County,State& Federal laws,codes,rules and regulations. Indicate Permit Tyne: Installation( ) •Removal •Abandonment( )/Above Ground ( )•Buried in Ground 1. Address:T� (� b� (,Lf r`o�Z t I l G L SBL: �3J�i r�1�y -�-cN Zone: 2. Property Owner&Address: A-i f�c�d-l- r I- 0-n (In ,, r 0.5 Phone#: Cj I - 3 Cell #: - ; _ -n(R---email:It,A � 3. Contractor&Address: L—n�t r S h I C( -h'1 C - :Rh C Phone#: ;?,()-)-31S0 -5-64 Cell 0: email: I ri-�n Cr1 CO ryl 4. Applicant: Lr-ci rr LA(j .­470C.kI LA Li - .� ✓I i�S�1 r � � ��� Phone k 20 3 -M�C;-- 5&14 Ccll 4: email: I n t-t) e r�✓, r ah rr��� Co 5. Indicate Fuel Type: Fuel Oil •L.P.Gas( )•Gasoline( )•Other( ):It- F- I f G ( CJ I 6. Number and Capacity of each Tank: _�� t'1 �� 10 0 C) -6-r2 C. n 7. Exact Locations)of each Tank: ( ►� 'f :11 I 10/30,'2023 W. .:.,INP-�`r y�.+�e1,1'.. =r d .41 0_-. .�ti, ,1'�=?�'� .3-a4,le,,'_•.�a ` - .hNeO�.`��:�,4�,�:�4Nu,..' ,..�.: i .1 co)s o u o <t >1 •�� > a. L OCV �J o G, y C X(J N v� \ / e 1 U 4.. o L LLI CD 2 E � j.r ti w Q Q O sue. A. o '_ a�1apLD f . x o z cc o CO c a• /� ca _ V C14 41 rA — — i'. . . . . . . . . . . . . . . �C«O)► gar -i - ao 'r 1 lji y '�°=�` 11 1, 1 •► 9 •1 ,1 _ .- ,1 '1 -..'.� (A)1� . +eey�, ,,,el ,,eN,, +,►ee,1 I,e►4'', ,,leiey4` ,+eoa+, eeo. ee♦,r� eo �,eee e�►o oeo O Nv a. . � v. ` . v • S ENVIINC-01 MTOMASELLI A�oRo CERTIFICATE OF LIABILITY INSURANCE DAT 1 17/2/17/2D2YYY) 024 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 CONTACT Mary Tomaselli NAME Gowrie Group PHONE FAX 70 Essex Road A/C (AIC,No): Westbrook,CT 06498 E-MAIL •mtomaselli@risk-strategies.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Nautilus Insurance Company 17370 INSURED INSURER B:Great Divide Insurance Com an 25224 Enviroshield Inc.and E.G.Kost Rental,LLC PO Box 1296 INSURERC: 250 Moffitt Street INSURERD: 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 7 OCCUR ECP01521982-24 12/1/2023 12/1/2024 DAMAGETO EREoNaurD $ 100,000 MED EXP(Any one rson $ 5,600 PERSONAL&ADV INJURY $ 1,000,000 NEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 POLICY a P 9- LOC GENERAL AGGREGATE $ 2,000,000 J PRODUCTS-COMP/OP AGG $ OTHER: B $ AUTOMOBILE LIABILITY COMBINED LE LIMIT $ 1,000,000 ANY AUTO BAP1521979-24 12/1/2023 12/1/2024 BODILY INJURY Per person) $ AAURRTO�S ONLY NED X SCHEDULED SSyUyLryEDp BODILY INJURY Per accident $ X AUT0.S ONLY X AUTOS ONLY PPaOaca�M AMAGE $ X MCS-90 End't F $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE FFX203675212 12/1/2023 12/1/2024 AGGREGATE $ 1,000,000 DIED I X I RETENTION$ 10,000 $ B WORKERS COMPENSATION X PERTLIT, OTH- AND EMPLOYERS'LIABILITY Y 50 23 12/1/2023 12JI12024 1,000,000 ❑ CA 12198 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ WFICER/MEMBE I EXCLUDED? N/A 1,000,UUU (Mandatory In% ) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space 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. AUTHORIZEDREPRESENTATIVE Village of Rye Brook F�yr"vJ►'�-�Vt 938 King Street iRye Brook NY 10573 ACORD 25(2016/03) ©1988-2015 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 la.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 requiredif coverage isspecifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, Le., 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"1 all WCA 1521980 23 Village of Rye Brook 938 King Street 3c. Policy effective period Rye Brook,NY 10573 12/1/23 to 12/1/24 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(NV)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 note the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums 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 one year 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: 1/17/2024 (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: Friday,January 19, 2024 12:25 PM To: Steven Fews Subject: Message from UDig NY ****REGIJLAR**** DIG REQUEST from UDig NY for: VIL RYE BROOK Taken: 01/19/2024 12:24 To: VIL RYE BROOK PRIMARY Transmitted: 01/19/2024 12:25 00004 Ticket: 01194-000-472-00 Type: Regular Previous Ticket: ------------------------------------------------------------------------------ State: NY County: WESTCHESTER Place: RYE BROOK Addr: From: 18 To: Name: CHURCHILL RD Cross: From: To: Name: Offset: ------------------------------------------------------------------------------ Locate: AREA IS MARKED IN WHITE. FRONT RIGHT NearSt: WINDINGWOOD RD N 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: 02/16/2024 Depth of excavation: 8 FEET Site dimensions: Length 8 FEET Width 5 FEET Start Date and Time: 01/24/2024 07:00 Must Start By: 02/07/2024 ------------------------------------------------------------------------------ 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: HOMEOWNER ------------------------------------------------------------------------------ Comments: Lookup Type: PARCEL ------------------------------------------------------------------------------ Members: ALTICE USA CONED SUEZ WTR WESTCHESTER VIL RYE BROOK WESTCHESTER CTY SWR i