APPROVED FM PLANSI I
riarneft
COUNTY
Fire Marshal Division
P.O. Box 370
Lillington, NC 27546
910-893-7580
Application for Tank Removal or Abandonment
Application # Date:
Applicant
--' 1 6
Billing Address
1-11, 0 1/4 Aj x/12 f4 1 L:
City S f F& ('14 State Zip ,� -7
Phone#
N
Location of Tank(s),BUFFHL-b i Wof* LU
Removal/Abandonment Date 'M
LU
Contractor Phone #
CC)
This application must be completed and returned to Central Permitting prior to
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the issuance of the permit. Please allow (7-10) working days for processing. A site 12�
ne-
inspection will be conducted to ensure compliance with applicable regulations. All feed:
shall be paid before permits will be issued. The following items are jgqq:ired to be -'-
submitted with this application.,
I Copy of North Carolina Department of Environment, Health and Natural
Resources GW/UST-3 Notice of Closure Intent.
2 Number of tanks to be removed including the capacity and contents of each tank.
3 Information detailing the proposed disposition of the tanks after removal.
It is the applicants responsibility to ensure that conditions are in accordance with all
applicable Federal, State and Local regulations.
Applicant Signature Date
1, ��H � 4 � 1. � � �; � �� -
14 -Sys
4L
Application for Tank Removal or Abandonment
Application # Date:
Applicant
--' 1 6
Billing Address
1-11, 0 1/4 Aj x/12 f4 1 L:
City S f F& ('14 State Zip ,� -7
Phone#
N
Location of Tank(s),BUFFHL-b i Wof* LU
Removal/Abandonment Date 'M
LU
Contractor Phone #
CC)
This application must be completed and returned to Central Permitting prior to
U -J
the issuance of the permit. Please allow (7-10) working days for processing. A site 12�
ne-
inspection will be conducted to ensure compliance with applicable regulations. All feed:
shall be paid before permits will be issued. The following items are jgqq:ired to be -'-
submitted with this application.,
I Copy of North Carolina Department of Environment, Health and Natural
Resources GW/UST-3 Notice of Closure Intent.
2 Number of tanks to be removed including the capacity and contents of each tank.
3 Information detailing the proposed disposition of the tanks after removal.
It is the applicants responsibility to ensure that conditions are in accordance with all
applicable Federal, State and Local regulations.
Applicant Signature Date
1, ��H � 4 � 1. � � �; � �� -
14 -Sys
1 20 to] 2701
#ffice of the Fire Marsh
P.O. Box 370
Lillington,27546
(910)-893-7580
W
Business Name: CAROLINA LAKES GOLF COURSE MAINT BLG
Address: 2955 BUFFALO LAKE RD
SANFORD, NC 27330
The following permit has been issued:
Permit No. 1850043587
Issued Date:
04/04/2018
Effective Date:
04/04/2018
Expiration Date:
10/04/2018
This permit certificate has been issued for Urconstruction I operational purposes located
at the above business location. This permit has been issued and will be enforced in accordance
with section 105 of the N.C. State Fire Prevention Code. Please contact our office for any further
questions regarding this permit.
Inspector:
mo
III
04/04/2018 Page 1
Divors, Inc.
42 Indian Trail
Sanford, NC 27332
Re: 2955 BuWalo Lake Road
Sanford, NC 27330
Application Number 18-50043587
To whom it may concern:
Thank you for submitting the plans for the installation of the above ground flammable
liquid storage tank(s) relocation. The plans have been carefully reviewed by a qualified
code enforcement official to examine for compliance with the North Carolina Fire
Prevention Code and all other fire protection regulatory documents. There are some
items that were found during the plan review process that need to be addressed before
a permit to install the tanks can be granted. These items are outlined and described
below.
After permit is issued and before final approval:
Installation shall be in accordance with all North Carolina Fire prevention codes
and NFPA 30 standards.
A final Fire inspection is required at the end of the project.
Call (910) 893-0743 to schedule all fire inspections.
Thank you again for submitting the plans for above ground storage tank relocation.
Please review the plans and adhere to any notes and alterations that were made in
addition to the original drawings. These remarks are for the plans that were submitted and
its original intent. These remarks do not apply if the original intent changes or what was
submitted on the above date changes. If you have any questions, please do not hesitate to
call this office.
Again, thank you and we look forward to working with you during the construction
period!
Sincerey,
Rodney Dan s
Chief Deputy Fire Marshal
Harneft
COUNTY
-!',Ian Review, Inspection., and Permit Fees
Application Number
1850043587
$200.00
❑
Explosive Material (90 Days)
$ -
$100.00
❑
Explosive Materials (72 Hours)
$ -
$100.00
❑
Fireworks Public Display
$ -
$50.00
❑
Final Inspection
$ _
$35.00 +$2.00 per device
❑
Fire Alarm Testing
$ -
$35.00 + $2.00 per nozzle
❑
Fixed Fire Suppression
$ -
$75.00
❑
Insecticide Fog/Fumigation
$ -
$100.00
❑
Pipe Test/UST/AGST
$ _
$50.00
❑
Plans up to 5000 sq ft
$ -
$100.00
❑
Plans 5001 sq ft to 10,000 sq ft
$ -
$150.00
❑
Plans 10,001 sq ft to 25,000 sq ft
$ -
$250.00
❑
Plans 25,001 sq ft and over
$ -
$35.00 +2.00 per head
❑
Sprinkler Certification Test
$ -
$50.00
❑
Standpipe Testing
$ _
$50.00
❑
Special Assembly
(ie. amusement buildings, carnivals, fairs)
$ -
$75.00
Tents/Canopies/Air Supported Structure
$100.00 Tank Installation (charge for each tank)
$ 100.00
$100.00 ❑ Tank Removal (charge for each tank) $ -
Total Devices/Heads $ -
Total st $ 100.00
Code Enforcement Official Rodney Daniels 4/4/201
Notice 1 4i
Rettlrttcompleted form to �STATE USE ONLY
The DWM Regional Office located in the area where the facility is located. Send a copy to the Central Office in Ralei so that
the status of the tank may be changed to "PERMANENTLY CLOSED" and your tank fee account can be closed out
SEE MAP ON THE SACT{ OF THIS FORM FOR THE CENTRAL AND REGIONAL OFFICE ADDRESSES. irate Reeved
_
INSTRUCTIONS (READ THIS FIRST)
I Complete and return at least thirty (38) days Prior to closure or change-in-service activities. If a Professional Engineer (P.E.) or a Licensed Geologist (L.G.)
t provides supervision for closure or change-in-service site assessment activities and signs and seals all closure reports then at least a five (5) working
days notice is acceptable.
Completed LIST closure or change-in-service site assessment reports, along with a copy of the UST-2 form, should be submitted to the appropriate Division
of Waste Management (DWM) Regional Office within thirty (30) days fallowing closure activities. The UST-2 form should also be submitted to the Central
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Office in Raleigh so that the status of the tanks may be changed to permanently closed and your tank fee account can be closed out.
f
UST closure and change-in-service site assessments must be completed in accordance with the latest version of the Guidelines for Site Checks, rank '
! Closure and Initial Response. The guidelines can be obtained at t~t�t ';www.wastenotr�c.r r !wet i yr ,t. Note: To close tanks in place you must obtain prior
approval from the DWM Regional office located in the region where the facility is bated,
You must make sure that LISTS removed from your property are disposed of property. When choosing a closure contractor, ask where the tank(s) will be
taken for disposal. Usually, USTs are cleaned and cut up for scrap metal, This is dangerous work and must be performed by a qualified company. Tanks
disposed of illegally in fields or other dumpsites can leak petroleum products and sludge into the environment. If your tanks are disposed of improperly, you
i could be held responsible for the cleanup of any environmental damage that occurs.
' 1. OWNERSHM OF TANKS _ II> LOCATION
Owner Name (Corporation Individual, Public Agency, or Other Entity} Facility Name or Company � _
t l f G a I &0 (14- -� S 4- ,Oc
Street Address �_ Facility ID # (if known)
City CountyStreet Address
State Zip Code City County Zip Code
fl_...
f Phone Number
l Ili. CONTACT PERSONNEL ,
Name: Company Name: Job Title: Phone Number:
_ IV. TANK REMOVAL, CLOSURE IN CiI -1
1. Contact local fire marshal. 5. Provide a sketch locating piping, tanks and a P.E. or L.G., with all closure site
2. Pian entire closure event, sail sampling locations. assessment reports bearing the signature
6. Submit a closure report in the format of and seal of the P.E. or L,G. If a release has
3. Conduct Site Soil Assessment not occurred,the supervision, signature or
UST-12 (including the form UST-2} within
4. If removing tanks or closing in place, refer to thirty (30) days fallowing the site seal of a P.E. or L.G. is not required,
API Publication 2015 Cleaning Petroleum investigation. & Keep closure records for three (3) years.
Storage Tanks and I&A Removal and 7. If a release from the tanks has occurred, the
{ Disposal of Used Underground Petroleum
Storage Tanks, site assessment portion of the tank closure
must be conducted under the supervision of
V. WORK TO BE PERFORMED BY
Cont�raetar Name: Contractor Company Name:
Ad rd ess: � � State: Zip Cade: __Phon_e No:
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t
I Primary Consultant Name; Primary Consultant Company Name: Consultant Phone No:
i
R V1. TANKS SCHEDULED FOR CLOSURE CHANGE—IN—SERVICE
Posed Activi
Closure u Cha-In-Service
Tank lD No_ Size in Gallons Last Contents Removal Abandonment in Place New Contents Stored
1 1
• Prior written approval tc abandon a tank in place must be received from a DVVM R tonal ce.
VIl R OROWNER'S AUTHORIZED NTS
I understand that I can be held responsible for environmental damage resulting from the improper disposal of my LISTS,
r Print name and official title:
Signa ire Date Signed— 1 ;CHEDULED REMOVAL DATE N-o if}r your i 6� ional t ce
48 hours before this date if
scheduled removal date changes �
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Green Tee Associates, Inc.
ToWhom ItMay Concern:
LJean Hubbard, President ofGreen Tee Associates, Inc, hereby grant Divots, Inc. the permission to
move the gas tanks currently located on their property to a new location designated on our property
adjacent tothe Carolina Lakes Golf Course.
Please contact meifyou require anything further.
Sincerely,
i4n A. Hubbard, President
Notary & Date
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