EFTA01221878.pdf

FORM U.S. ENVIRONMENTAL PROTECTION AGENCY I. EPA IM. NUMBER s 1 GENERAL %it EPA GENERAL INFORMATION Consolidated Permits Program (Read the "General Instructions" before starting.) F VI 0040525 t 2 13 VA 14 C D IS LABEL ITEMS GENERAL INSTRUCTIONS If a prepriited label has been prowled. affix it in the I. EPA.. NUMBER designated space. Review the information carefully: if any of it a incorrect. cross through it and enter the correct data in the appropriate fill.in area below. II. FACILITY NAME Also. if any of the prepnmed data a absent the area to the left of the label space lists the eiformation that should appear), please provide it in III. FACILITY MAILING PLEASE PLACE LABEL IN THIS SPACE the proper fill-in areals) below. If the label is ADDRESS complete and Correa you need not complete hems I. III, V. and Vhexcept VI-8 which must be completed regardless). Complete all items i no IV. FACILITY LOCATION label has been proved. Refer to the instructions for detaled item descriptions and for the legal authorization under which this data is collected. II. POLLUTANT CHARACTERISTICS INSTRUCTIONS: Complete A through J to determine whether you reed to submit any permit application forms to the EPA. I you answer yes' to any questions, you midst submit this form and the supplemental from listed in the parenthesis following the question. Mark 'X' in the box in the third column if the supplemental form is attached. If you answer 'no" to each question. you need not submit any of these toms. You may answer 'no' if your activity i$ excluded from permit requirements: see Section C of the instructions. See also. Section D of the instructions for definitions of bold-faced terms. MARK 1C' SPECIFIC QUESTIONS FORM SPECIFIC QUESTIONS MARK 1CFORAI YES NO YES NO ATTACHED ATTACHED A. Is this facility a publicly owned treatment B. Does or will this facility (either existing or works which results in a discharge to waters of ❑ Fr proposed) include a concentrated animal 0 r 0 the U.S.? (FORM 2A) feeding operation or aquatic animal production facility which results in a discharge 16 17 16 to waters of the U.S.? (FORM 28) 19 20 21 D. Is this proposal facility (other then those C. Is this facility which currently results in discharges to waters of the U.S. other than descnbed in A or 8 above) which will result in a ❑ r ❑ those described in A or B above? (FORM 2C) 22 21 U discharge to waters of the U.S.? (FORM 2D) 25 26 27 E. Does or will this faddy beat, store, or dispose of F. Do you or will you inject at this facility indusbial or hazardous wastes? (FORM 3) ❑ 62 ❑ municipal °fluent beta,/ the lowermost stratum containing. within one quarter mie of the well bore. 28 29 30 underground sources of drinking 6ster? (FORM 4) 31 32 73 G. Do you or will you inject at this facility any produced H. Do you or will you inject at this faddy fluids for water other fluids which are brought to the surface special processes such as mining of suffer by the in connection with conventional oil or natural gas productcn. nject fluids used for enhanced recovery ❑ L E Frasch process. solution mining of minerals. in situ combustion of fossil fuel, or recovery of • 0 MI of al or natural gas, or inject fluids for storage of geothermal energy? (FORM 4) baud hydrocarbons? (FORM 4) 34 35 36 37 3B se I. Is this facility a proposed stationary source J. Is this facility a proposed stationary source which is one of the 28 industrial categories listed which is NOT one of the 28 industrial categories 0 ❑ ® in the instructions and which wil potentialy emit 100 tons per year of any air pollutant regulated ❑ 0 listed in the instructions and which will potentiaity emit 250 tons per year of any air polutant 0 under the Clean Air Act and may affect or be regulated under the Crean Air Act and may affect located n an attainment area? FORM 51 40 41 42 or be located in an attainment are? FORM 5 43 44 45 III. NAME OF FACILITY c SKIP 1 15 76.29 10 69 IV. FACILITY CONTACT A. NAME & TITLE (last. first. & title) 8. PHONE (area code 8 no.) c Gordon Brice Manager 340 513 9855 2 15 tfl 45 48 48 49 51 52 65 V. FACILITY MAILING ADDRESS A. STREET OR M. BOX c 6100 Red Hook Quarters B-3 15 16 45 B. CITY OR TOWN C. STATE D. ZIP CODE c Saint Thomas VI 00802 4 15 16 40 41 42 47 61 VI. FACILITY LOCATION A. STREET. ROUTE NO. OR OTHER SPECIFIC IDENTIFIER c Little St. James Island 5 15 16 45 B. COUNTY NAME USA 46 70 C. CITY OR TOWN D. STATE E. ZIP F. COUNTY CODE CODE c N/A VI 00802 N/A 6 15 16 40 41 42 47 51 52 se EPA FORM 3510-1 (8-90) CONTINUED ON REVERSE EFTA01221878 CONTINUED FROM THE FRONT VII. SIC CODES (4-digit, in order of priority) A. FIRST B. SECOND c N/A (sPecifY) 7 N/A (sPecifY) 7 15 16 17 15 16 10 C. THIRD D. FOURTH c N/A (sPecifr) 7 N/A (sPecifY) 7 15 16 17 15 16 19 VIII. OPERATOR INFORMATION A. NAME B. Is the name listed in Item C Arran Mc Ginnis VIII-A also the owner? 8 ❑ YES El NO 18 C. STATUS OF OPERATOR (Enter the appropriate letter into the answer box: if 'Other." specify.) D. PHONE area code 44 no.) F = FEDERAL M = PUBLIC (other than federal or state) I p (specify) c 340 690 1 1487 S =STATE 0 = OTHER (specify) A P = PRIVATE 68 15 16 18 19 21 I 22 25 E. STREET OR PO BOX 6100 Red Hook Quarters B-3 26 66 F. CITY OR TOWN G. STATE H. ZIP CODE IX. INDIAN LAND C St. Thomas VI 00802 Is the facility located on Indian lands? B ' • YES E] NO t6 l8 a0 42 4 X. EXISTING ENVIRONMENTAL PERMITS A NPDES (Discharges to Surface Water) D. PSD (Air Emissions from Proposed Sources) C T I C T 6 N/A 9 N 9t 15 18 17 18 30 P l 17 18 15 18 30 B. UIC (Underground Injection of Fluids E. OTHER (specify) (Specify) ' 9 U 9 15 18 17 N/A 18 30 15 18 17 J 18 30 C. RCRA (Hazardous Wastes) E. OTHER (specifr) (Specify) C T I N/A C T 6 9 R 9 15 18 17 18 30 1 15 18 17 18 30 XI. MAP Attach to this application a topographic map of the area extending to at least one mile beyond property boundaries. The map must show the outline of the facility, the location of each of its existing and proposed intake and discharge structures, each of its hazardous waste treatment, storage, or disposal facilities, and each well where it injects fluids underground. Include all springs, rivers and other surface water bodies in the map area. See instructions for • ecise r- •uirements. XII. NATURE OF BUSINESS (provide a brief description) Private Residence, Domestic Use, Irrigation use. XIII. CERTIFICATION (see instructions) I certify under penalty of law that f have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibilit of fine and imprisonment. A. NAME 8 OFFICIAL TITLE (type or print) S. SIGNATURE C. DATE SIGNED Brice Gordon - Island Manager COMMENTS FOR OFFICIAL USE ONLY c C 15 16 55 EPA FORM 3510-1 01-90) EFTA01221879