HomeMy WebLinkAboutUnderground Storage Tanks 10/27/2011 23:32 7635311801 DEANS TANK INC PAGE 02
'Minntiism 00"UiwiilUnderground- 5torao Tanks vsTs)
On"Agency
Notification of Installation or Change in Status
insUtiation, New Information; Closure
i'
St.Pairl,AMS51BS-4194 .Tanks; Piping, Dispensers
N�rtify the Minnesota Pollution Control'Agency.(MPCA)within 30 days afbar bringtrig tank system into use yr change in status.
hep a Dopy for yo' records:Unsigned forms will be returned.Questions:Ca11851-297.-8864 or 1-800=65T-3884 during ngnnat '
bUslness.hours.'
UO*this form fvr: MPGA Use Oni
• Installation or replacement of tarik,piping,or dispensers Site#Z-
• Charge in intoMurtion.suclk as site name,address,owner,
county
or tank•contents .
I. . Change in tank stAtus,such as temporary or-Permanent Date recd:
i closure I Referred to: •
. 11V��ys.to nvtlfy:• . . .
• Fac . 654-297-2343 vr.'631-297.8683,Aft Joann Henry.
j : WK- Attai.ktam Henry at above address
Sit0166rmation .
site name: Site#.Qf known);
Address:
+
'State:. MN Zip code: 5 56 414-11County:
C
ntact name:
Phone:'
Is this site located on Native Arnorican lands? . [j Yes No
lel this the Initial notiflcatlon for this sibs?. '' ❑Yes Ne
.T�pe
-of facility:. ❑SenAce-station ❑Covemment ❑Education ❑lnduMry/Factory Q Auto dealer ❑Utility'.
[]8ulk.p i.ti Q Resort .Q.Offlce building Other(specify
OWner Information
Name:. _
A�Idress: ,A%a e 2 0
State: __ _ Zip code: ;�4e jyS 3
Co.Contact narie: �/ ►frr,r, Phone:
Al 4alo t(Enter date(M/D/YYYY)of action under tank nufnber)• '
1. Tank number
(for newslte,assign 3 digit O /
number
2.' Installed new tank'-
,3,1 Installed clew pipind
4:1.. Installed new dispenser(s)
s.i 'changed site name or
Information
6.1 owner
7.1 Cha jed store substance
6.1 Changed to nonregulated• .
substance
9. Temporarily dosed•tank
i and ' i fn place
1ol Removed tank pnd piping �-
II
1.012712011 23:32 7635311801 DEANS TANK INC PAGE 03
B: Tank ilnform Mfi
'I. Tank h miber ,
gor nasi oft=040 3MMO '
• • 2: i Stored si�larme►? . . .• •
I.(ff ttds b1Ac isoonQatrnentat. ' 1� .
• .stows to 4 ,
3. ' �O
4. ; Co—.. tam oily. -
WenffycwacKyand
subob n m for each
' cornporty *(9®9 chaff on
psM 4 forgUbMI cel
(oaa (goo" NOW (getlatsJ
. , 1 otker• . ter Other.
• ���� •�fel o�( .ate(�•*1
e onrN over : •
5 I Sde.use 019 Y NoE3 Yin Oft . Yes—AlNo Yes El.No
6. I Sale use wrwgmw.. El Ym Yes No No Yes No
7. Dual um Y No Yes No Yes
Yes No
goneraWWd
8. Tack type:omm•stied.S IM 0—
FRP,=ls%mK, v
9. 1 Secondary cot1t8YNIle11l ,
' I d�ouble•�eMed'a'tieal,double-• . .
J iWMdFRP.W44a coNd
dotAtlewalfed steal,singls- .
;gid atsl•rMtat FW.*l t
Mn,tntietstil0at .
10; ff tlirtk ries cathodic
pmtodkm(MwanW
I is Intetrral tmhk.9n Yes tZNo Yes No 13 Yes • No El Yesr3-No
12.1 tM pipe gm aonhlrtrtterd r7l•'Yes Ido Yeg No 13 y" 13 No 13 Yes 0No
131 oven prgi en n we
091 p**ftpplw.vdval vat
1 pips ISI I=L m dWo Mgb
*vw awn ram)-
14.1 Stage 1 vraporreoovmy for .
•asalrm Wft Yes 0 No 0 Yes 0 No 0 Yes n No Yes No
15.1 Primary method of tat*
(.'release detection (a*rt t
bm*9 (AT1b), y
conal.star ftal ImmntmY
i control(81 tw*
i
I
10127/2011 23:32 7635311801 DEANS TANK INC PAGE 04
a kalfication:
-'Tank Owner
#,4w*that the Ml Wm don&&TNW is a antgo and cch piste to the best of my knowledge;that lndmNe bra of tanked fig,and .
d pensers Is eaooraDnp'to IbtMn.R.ch.7150.aubps:0100 end D205,rnewing'saoandary containment of now and repbewrant
talks,piping,and dlsperrsera;and Nrat ad tanks end plph�y hays riNease detecdlon acooidlnA b Il�nn.l�di. 1150.sutra.0�0 Ib
d��{340(For owners purchasH►a tanks eRar March 1,2006,only)l certify that all tank operators,Includlrrq Mssaes,haus rated this
rhapterand have sulllF�ent knowMd�ps'Irr,the operafloa and neMtesnance of undslpround stara�tank ayatem� "
Nrme•of owner or, ----��.
oWne' es authertzed represent".(print): M Ir 6P AIV�Z E
r7 l
Tale: Dab:
j
.Signature•
T�nk.Contmctor
•.I far&that all work was performed as.specified by the manufacturer's irtstriscW that aN wm1lc was perlbbm®d according b the
a/jp6oable codes of prgcBi:e!n Mjnn.R.'ch.,7150,.,sybp.0205;that all work�vas parform�d acco�lrrg fo appQcse•stete end rederal
r+�qulatlons,lndud/ng Ehle chapter,and that/em In oompAanoe Woh cc idsctor carMation requimments imposed by Minn;R.cli.
7150.
MPGA auWvWor Tank contractor or
o alts during tank contractors audwrlmd
rk(printi: /Ir�E?`/ representative.(print): .-Ad /S T wk^ !✓C-
y0/ r Data'
.Too, Title:
4nalure: Signature: T
MPCA �.
9up®N� o #: - Contractor-*
j
i
j
i •
I;
t-1-04
$P,
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