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10/27/2011 23:32 7635311801 DEANS TANK INC PAGE 02 <br /> 'Minntiism 00"UiwiilUnderground- 5torao Tanks vsTs) <br /> On"Agency <br /> Notification of Installation or Change in Status <br /> insUtiation, New Information; Closure <br /> i' <br /> St.Pairl,AMS51BS-4194 .Tanks; Piping, Dispensers <br /> N�rtify the Minnesota Pollution Control'Agency.(MPCA)within 30 days afbar bringtrig tank system into use yr change in status. <br /> hep a Dopy for yo' records:Unsigned forms will be returned.Questions:Ca11851-297.-8864 or 1-800=65T-3884 during ngnnat ' <br /> bUslness.hours.' <br /> UO*this form fvr: MPGA Use Oni <br /> • Installation or replacement of tarik,piping,or dispensers Site#Z- <br /> • Charge in intoMurtion.suclk as site name,address,owner, <br /> county <br /> or tank•contents . <br /> I. . Change in tank stAtus,such as temporary or-Permanent Date recd: <br /> i closure I Referred to: • <br /> . 11V��ys.to nvtlfy:• . . . <br /> • Fac . 654-297-2343 vr.'631-297.8683,Aft Joann Henry. <br /> j : WK- Attai.ktam Henry at above address <br /> Sit0166rmation . <br /> site name: Site#.Qf known); <br /> Address: <br /> + <br /> 'State:. MN Zip code: 5 56 414-11County: <br /> C <br /> ntact name: <br /> Phone:' <br /> Is this site located on Native Arnorican lands? . [j Yes No <br /> lel this the Initial notiflcatlon for this sibs?. '' ❑Yes Ne <br /> .T�pe <br /> -of facility:. ❑SenAce-station ❑Covemment ❑Education ❑lnduMry/Factory Q Auto dealer ❑Utility'. <br /> []8ulk.p i.ti Q Resort .Q.Offlce building Other(specify <br /> OWner Information <br /> Name:. _ <br /> A�Idress: ,A%a e 2 0 <br /> State: __ _ Zip code: ;�4e jyS 3 <br /> Co.Contact narie: �/ ►frr,r, Phone: <br /> Al 4alo t(Enter date(M/D/YYYY)of action under tank nufnber)• ' <br /> 1. Tank number <br /> (for newslte,assign 3 digit O / <br /> number <br /> 2.' Installed new tank'- <br /> ,3,1 Installed clew pipind <br /> 4:1.. Installed new dispenser(s) <br /> s.i 'changed site name or <br /> Information <br /> 6.1 owner <br /> 7.1 Cha jed store substance <br /> 6.1 Changed to nonregulated• . <br /> substance <br /> 9. Temporarily dosed•tank <br /> i and ' i fn place <br /> 1ol Removed tank pnd piping �- <br /> II <br />