FORM 1 GENERAL U.S. ENVIRONMENTAL PROTECTION AGENCY I. EPA IM. NUMBER GENERAL INFORMATION s VA C %it EPA Consolidated Permits Program "General FVI 0040525 D (Read the Instructions" before starting.) t 2 13 14 IS LABEL ITEMS GENERAL INSTRUCTIONS I. EPA.. NUMBER If a prepriited label has been prowled. affix it in the designated space. Review the information carefully: if any of it a incorrect. cross through it and enter the II. FACILITY NAME correct data in the appropriate fill.in area below. Also. if any of the prepnmed data a absent the area to the left of the label space lists the III. FACILITY MAILING ADDRESS PLEASE PLACE LABEL IN THIS SPACE eiformation that should appear), please provide it in the proper fill-in areals) below. If the label is complete and Correa you need not complete hems I. III, V. and Vhexcept VI-8 which must be IV. FACILITY LOCATION II. POLLUTANT CHARACTERISTICS INSTRUCTIONS: Complete A through this form 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 reed to submit any permit application forms to the EPA. I in the parenthesis following the question. Mark 'X' in the box in the third column if the of these toms. You may answer 'no' if your activity i$ excluded from permit requirements: terms. completed regardless). Complete all items i no label has been proved. Refer to the instructions for detaled item descriptions and for the legal authorization under which this data is collected. you answer yes' to any questions, you midst submit supplemental form is attached. If you answer 'no" to see Section C of the instructions. See also. Section D 1C' MARK FORM MARK 1C SPECIFIC QUESTIONS YES NO ATTACHED SPECIFIC QUESTIONS YES NO FORAI ATTACHED A. Is this facility a publicly owned treatment works which results in a discharge to waters of the U.S.? (FORM 2A) ❑ FrB. 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 r 0 16 17 16 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 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 hazardous wastes? (FORM 3) ❑ 62 ❑ F. Do you or will you inject at this facility indusbial or 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 water other fluids which are brought to the surface in connection with conventional oil or natural gas productcn. nject fluids used for enhanced recovery of al or natural gas, or inject fluids for storage of ❑ L E H. Do you or will you inject at this faddy 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) • 0 MI baud hydrocarbons? (FORM 4) 34 35 36 37 3B se I. Is this facility a proposed stationary source which is one of the 28 industrial categories listed the instructions and which wil potentialy emit 100 tons per year of any air pollutant regulated under the Clean Air Act and may affect or be ❑ 0 J. Is this facility a proposed stationary source which is NOT one of the 28 industrial categories listed in the instructions and which will potentiaity emit 250 tons per year of any air polutant regulated under the Crean Air Act and may affect ❑ 0 0 ® in located n an attainment area? FORM 51 III. NAME OF FACILITY 40 41 42 or be located in an attainment are? FORM 5 43 44 45 c SKIP 1 15 IV. 76.29 FACILITY 10 CONTACT 69 A. NAME & TITLE (last. first. & title) 8. PHONE (area code 8 no.) cGordon Brice Manager 340 513 9855 2 15 tfl 45 48 48 49 51 52 65 V. FACILITY MAILING ADDRESS A. STREET OR M. BOX c6100 Red Hook Quarters B-3 15 16 45 B. CITY OR TOWN C. STATE D. ZIP CODE c Saint Thomas VI 00802 4 15 VI. 16 40 FACILITY LOCATION A. STREET. ROUTE NO. OR OTHER SPECIFIC IDENTIFIER 41 42 47 61 cLittle St. James Island 5 15 16 45 B. COUNTY NAME USA 46 70 C. CITY OR TOWN D. STATE E. ZIP CODE F. COUNTY 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 cN/A (sPecifY) 7N/A (sPecifY) 7 7 15 16 17 15 16 10 C. THIRD D. FOURTH cN/A (sPecifr ) 7N/A (sPecifY) 7 7 15 VIII. 16 17 OPERATOR INFORMATION A. NAME 15 16 19 B. Is the name listed in Item CArran 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 S =STATE 0 = OTHER (specify) (specify) c 340 690 11487 A P = PRIVATE 68 1516 1819 21I 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 CSt. Thomas VI 00802 Is the facility located on Indian lands? B ' • YES E] NO t6 X. l8 a0 EXISTING ENVIRONMENTAL PERMITS A NPDES (Discharges to Surface Water) 42 4 D. PSD (Air Emissions from Proposed Sources) C T I N/A C T 6 9 N P5 9t l 15 18 17 18 30 1 18 17 18 30 B. UIC (Underground Injection of Fluids E. OTHER (specify) (Specify) ' 9 U 9 15 18 17 18N/A 30 15 18 17 J 18 30 C. RCRA (Hazardous Wastes) E. OTHER (specifr) (Specify) C T IN/A CT69 R 9 15 XI. Attach show hazardous rivers 18 MAP 17 to this the and 18 30 1 application a topographic map of the area outline of the facility, the location of each waste treatment, storage, or disposal facilities, other surface water bodies in the map area. 15 18 extending of its and See instructions 17 18 30 to at least one mile beyond property existing and proposed intake and discharge each well where it injects fluids underground. for • ecise r- •uirements. boundaries. The map must structures, each of its Include all springs, 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 c FOR OFFICIAL USE ONLY C 15 16 55 EPA FORM 3510-1 01-90) EFTA01221879