FORM I GENERAL U.S. ENVIRONMENTAL PROTECTION AGENCY I. EPA I.D. NUMBER PA GENERAL INFORMATION s VA C %AO E Consolidated Permits Program "General F D (Read the Instructions" before starting.) 1 2 13 14 IS LABEL ITEMS GENERAL INSTRUCTIONS I. EPA I.D. NUMBER If a preprnted label has been provided. affix it in the designated space. Review the informabon carefully: if any of it is incorrect. cross through it and enter the II. FACILITY NAME correct dat ny a in the appropriate fill.in area below. Also. if a of the prepnmed dala is absent (the area to the left of the label space lists the III. FACILITY MAILING ADDRESS PLEASE PLACE LABEL IN THIS SPACE nbrmation that should appear). please provide it in the proper filin areals) below. If the label is complete and Carted you need not complete Items I. III, V. and Vftexcect VI-8 which must be N. FACILITY LOCATION II. POLLUTANT CHARACTERISTICS INSTRUCTIONS: Complete A through this tom and the supplemental from listed each question. you need not submit any of the instructions for definitions of bold-faced J to determine whether you need to submit any permit applicabon forms to the EPA. I in the parenthesis following the question. Mark 'X' in the box in the third column if the of these forms. You may answer 'no' if your activity is excluded from permit requirements: terms. completed regardless). Complete all items dno completed haS been proved. Refer to the instructions for detated item descriptions and for the legal authorization under which this data is collected. you answer yes' to any questions. you must Subait supplemental form is attached. If you answer 'no" to see Section C of the instructions. See also. Section D MARK 'X' MARK "XSPECIFIC QUESTIONS YES NO FORM ATTACHED SPECIFIC QUESTIONS YES NO FORM ATTACHED A. Is this facility a publicly owned treatment works which results in a discharge to waters of the U.S.? (FORM 2A) B. Does or will this facility (either existing or proposed) include a concentrated animal feeding operation or aquatic animal production facility which results in a discharge 0 • 0 16 17 18 to waters of the U.S.? (FORM 28) 19 20 21 C. Is this facility which currently results in❑discharges to waters of the U.S. other than❑ ❑ D. Is this proposal facility (other then those D 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 hazardous wastes? (FORM 3) F. Do you or will you inject at this facility industrial or 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 water other fluids which are brought to the surface in comecbco with conventional oil or natural gas production. sled fluids used for enhanced n.‘cnury of oil or natural gas, or inject fluids for storage of ❑ 0 • H. Do you or will you inject at this facility fluids for special processes such as mining of suffer by the Frasch process. solution mining of minerals. in situ combustion of fossil fuel, or recovery of geothermal energy? (FORM 4) .❑ MI baud hydrocarbons? (FORM 4) 34 35 36 37 36 se I. Is this facility a proposed stationary source which is one of the 28 industrial categories listed in the Instructions and which ved potentiay emit 100 tons per year of any air pollutant regulated under the Clean Air Act and may affect or be ❑ • J. Is this tacitly a proposed stationary source which is NOT one of the 28 industrial categories instructions in the instruct s and which will potentia/fy emit 250 tons per year of any air polutant regulated under the Clean Ax Act and may affect 0❑ 00 located in an attainment area? FORM 5 III. NAME OF FACILITY 40 41 42 or be located in an attainment are? FORM 5 43 44 45 CSKIP 1 15 IV. t6.29 FACILITY 30 CONTACT 69 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 VI. 18 40 FACILITY LOCATION A. STREET. ROUTE NO. OR OTHER SPECIFIC IDENTIFIER 41 42 47 51 c 5 15 16 45 B. COUNTY NAME 46 70 C. CITY OR TOWN D. STATE E. ZIP CODE F. COUNTY 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 (Welly) 7 7 15 16 17 15 16 19 C. THIRD D. FOURTH c (specify) 7 (VeCifY) 7 7 15 VIII. is 17 OPERATOR INFORMATION A. NAME is 16 19 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) S = STATE O = OTHER (specify) (specify) c A 15 P = PRIVATE 68 16 18 19 1 22 25 E. STREET OR PO BOX 26 s s 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 X. l8 so EXISTING ENVIRONMENTAL PERMITS A NPDES (Discharges to Surface Water) 42 42 D. PSD (Air Emissions 47 61 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 c 6 9 ill U 9 116 15 18 17 I 18 30 15 I 17 J 18 30 C. RCRA (Hazardous Wastes) E. OTHER (specifr) (Specify) C T I C T 6 9 R 9 IS XI. Attach show hazardous 18 MAP 17 to this the 18 30 application a topographic map of the area outline of the facility, the location of each waste treatment, storage, or disposal facilities, 15 18 17 extending of its existing and each 18 30 to at least one mile beyond property and proposed intake and discharge well where it injects fluids underground. boundaries. The map must structures, each of its 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 c FOR OFFICIAL USE ONLY C IS 18 55 El'A FORM :1510-1 (K-911) EFTA01221077