EFTA01221076.pdf

FORM U.S. ENVIRONMENTAL PROTECTION AGENCY I. EPA I.D. NUMBER GENERAL INFORMATION s EPA VA C I %AO Consolidated Permits Program F D GENERAL (Read the "General Instructions" before starting.) 1 2 13 14 IS LABEL ITEMS GENERAL INSTRUCTIONS If a preprnted label has been provided. affix it in the I. EPA I.D. NUMBER designated space. Review the informabon carefully: if any of it is 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 dala is absent (the area to the left of the label space lists the nbrmation that should appear). please provide it in III. FACILITY MAILING PLEASE PLACE LABEL IN THIS SPACE the proper fil in areals) below. If the label is ADDRESS complete and Carted you need not complete Items I. III, V. and Vftexcect VI-8 which must be completed regardless). Complete all items dno N. FACILITY LOCATION haS been proved. Refer to the instructions for detated 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 need to submit any permit applicabon forms to the EPA. I you answer yes' to any questions. you must Subait this tom 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 forms. You may answer 'no' if your activity is excluded from permit requirements: see Section C of the instructions. See also. Section D of the instructions for definitions of bold-faced terms. SPECIFIC QUESTIONS MARK SPECIFIC QUESTIONS YES NO 'X'FORM YES MARK NO "XFORM 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 proposed) include a concentrated animal 0 • 0 the U.S.? (FORM 2A) feeding operation or aquatic animal production facility which results in a discharge 16 17 18 to waters of the U.S.? (FORM 28) 19 20 21 C. Is this facility which currently results in D D. Is this proposal facility (other then those discharges to waters of the U.S. other than ❑ ❑ ❑ descnbed in A or B above) which will result in a those described in A or B above? (FORM 2C) 22 23 24 discharge to waters of the U.S.? (FORM 2D) 25 28 27 E. Does or will this faaMy beat, store, or dispose of F. Do you or will you inject at this facility industrial or hazardous wastes? (FORM 3) muricirel effluent below the lowermost stratum containing. wit in one quarter rile ct the well bore. 28 29 30 underground sources et drinking instal (FORM 4) 31 32 33 G. Do you or will you inject at this facility any produced H. Do you or will you inject at this facility fluids for water other fluids which are brought to the surface special processes such as mining of suffer by the in comecbco with conventional oil or natural gas ❑ 0 • Frasch process. solution mining of minerals. in .❑ MI production. sled fluids used for enhanced n.‘cnury situ combustion of fossil fuel, or recovery of of oil or natural gas, or inject fluids for storage of geothermal energy? (FORM 4) baud hydrocarbons? (FORM 4) 34 35 36 37 36 se I. Is this facility a proposed stationary source J. Is this tacitly a proposed stationary source which is one of the 28 industrial categories listed which is NOT one of the 28 industrial categories 0 ❑ 0 in the Instructions and which ved potentiay emit ❑ • in the instruct instructionss and which will potentia/fy 0 100 tons per year of any air pollutant regulated emit 250 tons per year of any air polutant under the Clean Air Act and may affect or be regulated under the Clean Ax Act and may affect located in an attainment area? FORM 5 40 41 42 or be located in an attainment are? FORM 5 43 44 45 III. NAME OF FACILITY C SKIP 1 15 t6.29 30 69 IV. FACILITY CONTACT A. NAME 8. TITLE (last. (hist. 8 title) B. PHONE (area code 8, no.) c 2 15 16 45 48 48 49 51 52 65 V. FACILITY MAILING ADDRESS A. STREET OR MI. BOX c 3 15 16 45 B. CITY OR TOWN C. STATE D. ZIP CODE c 4 15 18 40 41 42 47 51 VI. FACILITY LOCATION A. STREET. ROUTE NO. OR OTHER SPECIFIC IDENTIFIER c 5 15 16 45 B. COUNTY NAME 46 70 C. CITY OR TOWN D. STATE E. ZIP F. COUNTY CODE CODE c 6 15 16 40 41 42 47 51 52 54 EPA FORM 3510-1 (8-90) CONTINUED ON REVERSE EFTA01221076 CONTINUED FROM THE FRONT VII. SIC CODES (4-digit, in order of priority) A. FIRST B. SECOND c (spec)fYl 7 7 (Welly) 7 15 16 17 15 16 19 C. THIRD D. FOURTH c (specify) 7 (VeCifY) 7 7 15 is 17 is 16 19 VIII. OPERATOR INFORMATION A. NAME B. Is the name listed in Item c VIII-A also the owner? 8 ❑ YES 0 NO 18 19 55 C. STATUS OF OPERATOR (Enter the appropriate letter into the answer box: if 'Other." specify) D. PHONE (area code a no.) F = FEDERAL M = PUBLIC (other than federal or state) (specify) c S = STATE O = OTHER (specify) A P = PRIVATE 68 15 16 18 19 1 22 25 E. STREET OR PO BOX 26 ss F. CITY OR TOWN G. STATE H. ZIP CODE IX. INDIAN LAND c Is the facility located on Indian lands? B ❑ YES D NO t6 l8 so 42 42 47 61 X. EXISTING ENVIRONMENTAL PERMITS A NPDES (Discharges to Surface Water) D. PSD (Air Emissions from Proposed Sources) C T I C 7 6 9 N 9 P 15 18 17 18 30 15 18 17 18 30 B. UIC (Underground Injection of Fluids E. OTHER (specify) (Specify) cr il l c 6 9 U 9 15 18 17 I 18 30 15 1 16 I 17 J 18 30 C. RCRA (Hazardous Wastes) E. OTHER (specifr) (Specify) C T I C T 6 9 R 9 IS 18 17 18 30 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) XIII. CERTIFICATION (see instructions) I certify under penalty of law that I 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 possibility of fine and imprisonment. A. NAME & OFFICIAL TITLE (type or pent) B. SIGNATURE C. DATE SIGNED COMMENTS FOR OFFICIAL USE ONLY c C IS 18 55 El'A FORM :1510-1 (K-911) EFTA01221077