NCS000570_Application_20140122

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Form Approved. OMS No. 2040-0086. Q all,
FORM
_, 'U.S. ENVIRONMENTAL PROTECTION AGENCY
I. EPA I.D. NUMBER ;
GENERAL. IN FORMATION
A
Consolidated Permits Program
REPA
GENERAL
(Read the "General Instructions"
before starting.)
1
z 1]
I• Is
LAB
L TEMS
GENERAL INSTRUCTIONS
If a preprinted label ;has been provided, affix`
\ation
`
it in the designated space. Review the inform-:
carefully; if any of it is incorrect, cross
through it and enter the correct data in the
appropriate fill=in area below, Also, if any ofthe preprinted data is absent (the area to the:
Y NAME
rADUMBER
\
left of the label space lists 'the information
ADDRESS
PLEASE PLACE"LABEL IN
THIS SPACE
that should appear), please provide it in the'
proper fill—in area(sl :below. if the label is.complete and correct, you need not complete ,
Items I, 111, V, and V I (except V7-8 whichmust be completed .regardless). Complete allY
N \
'�
items if no label has.been provided. Refer to
the instructions for',detailed item descrip-
tions and for the legal authorizations under
which this data is collected.
If. POLLUTANT CHARACTERISTICS'
INSTRUCTIONS: Complete A through J to de'termine.whether 'you need to
submit any permit application forms to the EPA. If you answer "yes" to any
questions, you must submit this form and the supplemental form 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 11no11 if ,your activity, y
is excluded from permit requirements; see Section C of the instructions. See also, Section D of the instructions for definitions of bold-faced terms.
-
MARK'X'
SPECIFIC Quir STiONS -
YES
ND
TTACNED
wN
SPECIFIC QUESTIONS
YEs
ND
ATTACH EO
A. 1s this facility a publicly owned treatment . works
✓
B. Does or will this facility (either existing or proposed)
include a concentrated animal feeding operation or
which results in a discharge to waters of the U.S.?
hi(FORM results
aquatic animal production facility which results. in rr
16
17
s
discharge to waters of the U.S2 (FORM 28)
Z
:,
C. is this a facility which currently results in discharges
/
D. Is This a propose facility other than those described
to waters of the U.S. other than those described in
I
in A or B ;abovel which will result in a discharge to
A or B above? (FORM 2C).
s
14 1
waters of the U.S.? (FORM 2D)
29
1 26
27
�._._
facility treat, store, or dispose of
E. Does or will this'
F. Do you or wift you inject at this facility industrial or
municipal effluent below the lowermost stratum con-'
hazardous waster(FORM 3)
taining, within one quarter mile of the well bore,
underground sources of drinking water? (FORM 4)`
31
32
33
G. o you or w-iff you Inject at this facilityany produced
water or other fluids which are brought to the surface
H. Do you or will you inject at this facility fluids for spe-
by Frasch
in connection with conventional oil or natural gas pro-
duction, inject fluids for enhanced recovery of,
cial processes such as mining of sulfur the
process, solution mining of minerals, in situ combus-r'
/
used
oil or natural gas, or inject fluids'for storage of liquid
tion of fossil fuel, or recovery of geothermal energyi
V
hydrocarbons? (FORM 4)
,.
s9
]6
(FORM 4)
3
I. s this fa8ility a propose statlpnarysource which is
J. Is this facility a proposed stationary source which Is
'.
one of the 28 industrial categories listed inthein-
NOT one of the 28 industrial categories listed'in"the,
structions and which will potentially emit 100 tons
the
instructions and which will potentially emit 250 tans
the Glean
=;
per .year of any air pollutant ,regulated under
per year of any air pollutant regulated untler
':eft
Clean Air Act and may affect or be located'in an
Air Act and may affect or be located ina':e it'
attainment area?>(�FORM 5l"
area? (FORM'-5)
:• aw
, f
sa "�
Ill, NAME OF FACILITY`
.� SKIP C U S"T Y v .lam A CS 1. fi rl .L vrT L V. y A L t Y
IV. FACILITY CONTACT
. - NAME a TITLE (Fast, first; & tttleJ�' �'
,. ' ., .B. PHoNE (a Yda,ColfC
2
HLMA i AWE YASusNT P.LA14
t� �.
2,621 y I P.0,03
V. FACILITY MAILING ADDRESS '
A. STREET OR P.O. BOX=,'.
c
s 12 I � suGG P HR 1CvlAY
=3
19 16
B. CITY OR TOWN
C:STATE D. SIP CODE
aC��?6EN�ZLL.t
WC 2TZ
VI. FACILITY LOCATION
A. STREET, ROUTE NO. OR OTHER SPECIFIC IDENTIFIER
TI 12.1 5 Sv � G JP UK Y �Y
JAI 2 2 2014
DENR - _WA AM ITY .r
,5 ,6
•S
B. COUNTY NAME
-
PLT T
of
C. CITY OR TOWND,STATE`.
E."ZIP CODE
F. COV
k,
UIvn
`.
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V C—
EPA Form 3510-1 (8-90) CONTINUE ON REVERSE

slA R1TIRl11CA CQnRA TWIZ rnnNT
VII. SIC CODES (4-digit, in order of priority/
A. FIRST ... B. SECOND
Eli
1!
(specil)v J1 t � �
(specify)
C. THIRD - - D.FOURTH`
c
(specify) ° (specify)
7
7
VIIi.OPERATOR INFORM
A. NAME '
8,- Is the name fisted in
Itsm Vtlf-A also the
owner?
L l YES Lv11N O
fifi
s
ili l S l �( i A C Ft E Ni i c a 1- u,s,A, 1' I mo'
.ice
C. STIAT US OF OPERATOR (Enter the approprfa[e letrer into the answer box: if ':0ther", Speci,f}'.�
D. PHONE (area cote $: no,)
F = FEDERAL M = PURL iC (other than federal orslate)
$ = STATE O - OTHER (specify)
P
(speci(ri
`
A
1r5 Z
1
r
(% 1 3
'
P = PH1VA'iE
S4
1s
+i - fs
Is - 21
22 2s
8, STREET OR P.O. 80X
,
J
1 2 1 5 5t1 GG P AQ KwA
F. CITY OR TOWN -
G.STATE H. ZIP CODE:
IX.ANDfAN LAND
c Is the facility Located on than lands?
NG 2 7$ 3 �' Q YEs "..Vrvo'
40 if 42 47 S1
X. EXISTING ENVIRONMENTAL PERMIT
A. NPOES (Disc)Iarges to Surface Water) _ .D. PSD (Air /:missions from Proposed'Sourees)
9 INJ I
51 16 t17 114 30 1] tf I 1) II '..-.... - - ... 30 ''' -. ...... .... ., . ...
B. u1C (Underground Injection ofFluidsJ E. OTHER (specify
o
(specify)9
M
I
t5
19 - - 30
ti
tf
11 3U
C. RCRA (Hazardous Wastes)
E. OTHER (specify)
(specify)
Rp
If
Attach to this application a topographic map of the area extending to'at least one mile beyond praperty bounderies,`The rnagrnust shg
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, ar; disposal facilities, and each well where'.it injects fluids underground In ude.111 ,,all springs rivers and other surface "
water:bodies in the map area. See instructions for precise requirements;
.fF
X11. NATURE OF BUSINESS (provide a brief description .
�Ji 1 1 CC,-
XI11. CERTIFICATION (seefnstructionsl
/ certify under penalty of law that / have personally examined and am familiar with the information submitted in this application and
attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information contained in the
application, / believe that the information is true, accurate and complete. l am aware that there are significant penalties for submiti-
false information, including the possibility of fine and imprisonment.
A. NAME & OFFICIAL TITLE (type or print) B. SIGNATURE C. DATE SIGNED
<?� �i 16, -2�r
COMMENTS FOR OFFICIAL USE ONLY
C
EPA Forfn 3510-1 (8-90)