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3380 Hwy 149 - Fuel Tank removal06/29/2009 11:01 FAX 6083562770 33.60 NSA J011131-- GFS Elf 1N! S-b•rorw & . rclt /2`• 6+15 As•••Zu AffiAlr fa 0007/0011 ...•s.•sty Aewl- I.,..k k "qv, t\.\t\ F+wt 33 r© Da ,p9 6 An. 1. Tank number; - See Guidance - page 4 2. Install new tank -- 3. Install new piping -- 4. Install new tank and piping — 5_ Install new dispenser(s) 6. Change site information .- 7. Change owner information 8. Change tank information 9. Change piping, pump, or dispenser information 9 10. Current tank status See Guidance .- page 4 Status: t� e' Date: �S'a., -=01 Status: Date: Status: Date: Status: Date: 11. If tank has been removed, list tank sludge disposal company and Hazardous Waste Generator 1D# p.e-/-7ter . 15,;J,,..,: ` e C. Minnesota Pollution Control Agency 520 Lafayette Road North Notification of Installation or Change in Status St. Paul, MN 55155 -4194 Installation, New Information, Closure Tanks, Piping, Dispensers Notify the Minnesota Pollution Control Agency (MPCA) within 30 days after bringing tank system into use or making a change in status or information. keep a copy for your records. Unsigned and incomplete forms will be returned Questions; Call 651- 757 -2429 or 1- 800- 657 -3864 during normal business hours. Use this form for: • Installation or replacement of tank, piping, or dispensers • Change in information, such as site name, address, owner, or tank contents • Change in tank status Ways to notify:; • Fax: 651- 297 -2343 or 651-297-8683, Attn: Joann Henry • Mail: Attn: Joann Henry at above address Site Information Site name: Address: S ?gO 1, ( 12, City: '' ... State: MN Zip code: 657a County: Contact name: Sfe -.e *re's Phone: la - 5 63 - CJ zi Is this site located on Native American lands? ❑ Yes.--- es No Is this the initial notification for this site? .Ees ❑ No Type of facility: ❑ Service station ❑ Govemment ❑ Education ndustry/Factory ❑ Auto dealer ❑ Utility 0 Bulk plant ❑ Resort ❑ Office building ❑ Other (specify): Owner Information Name: Address: 3 1ST k , City: Y� Contact name: Z ��e. A. Action (Enter date [MM/DD/YYYY] of action under tank number) t -u5 -04 • 12/3/08 Underground Storage Tanks MPCA Use Only Site #: County: Date rec'd: Site # (if known): State: jLytl Zip code: .S Phone: G (2 9(, `3 - 8 / £{ 7 www.pca.state.mn.us • 651 -296 -6300 • 800- 657 -3864 • TTY 651 -282 -5332 or 800 - 657 -3864 • Available in alternative formats Page 1 of 5 1. Tank number - See Guidance - page 4 (7 Cam( 0 C7 2 Capacity Gallons: Lj Gallons: Gallons: Gallons: 3. Stored substance See Guidance - page 4 Type : -S `c'., / Sped. R Type: Specify: Type: Specify Type: Specify: 4. Compartmental tank only See Guidance - page 4 Compartment 1 Compartment 2 Gallons: Gallons: Type: +��i� Gallons: Type: Gallons: Type: . - . . : . Gallons: Type: Type: ° -^-^ -, S... Gallons: Type: --- Gallons: Type: Gallons: Type: Compartment 3 Gallons pece7v: Gaffons: Specify* Gallons: SPecifY Gallons: Type: Sped . 5. Special use (check either or both if applicable) . -citing ; Q Generator fuel 0 Heating 0 Generator fuel Q Heating Q Generator fact 0 Heating 0 Generator fuel 6. Tank type See Guidance - ,4.∎ - 4 .1...4 : .: - S. Type: '`r marts . 7. Tank corrosion protection See Guidance - page 4 8. Fill pipe spill containment (spill bucket) 0 Yes No 0 Yes 0 No 0 Yes 0 No 0 Yes Q No 9. Overfill prevention type See Guidance - page 4 Ac 10. Stage 1 vapor recovery for gasoline tanks 0 Yes , , o Q Yes 0 No 0 Yes Q No Q Yes ❑ No 11. Primary method of tank release detection See Guidance -page 4 PczAl ��� �tt �'t C. Piping, Pump, and Dispenser Information: 1. Tank number See Guidance - page 4 0 C7 2. Piping type See Guidance -page 4 " c Type: S - c-e-1 Specify. Type: Specify: Type: Specify: Type: Soec+fi 3. Piping corrosion protection See Guidance - page 4 L7 4. Primary method of piping release detection See Guidance - page 4 5. Dispensing type See Guidance - page 4 4.4. 6. Submersible pump containment See Guidance -page 4 Type: ij !2 Specify Type: Specify. Type: Specify: Type: SPe Y-' 7. How many dispensers serve this tank? 8. Dispenser containment See Guidance - page 4 Type: Specify: -U Type: Specify: Type: Specify: Type: Specify: B. Tank Information Comments: www.pca.state.mn.us • 651 -296 -6300 • 800-657-3864 • TTY 651 - 282-5332 or 800-657 -3864 • Available in altemat formats t -u5-04 • 12/3/08 Page 2 of 5 Certification: Tank Owner I certify that the information submitted is accurate and complete to the best of my knowledge; that installation of tanks, piping, and dispensers is according to Minn. R. ch. 7150.0100 and 7150.0205, including secondary containment of new and replacement tanks, piping, and dispensers; and that all tanks and piping have release detection according to Minn. R. ch. 7150. 0300 to 7150.0340. (For owners purchasing tanks after March 1, 2008, only) I certify that all tank operators, including lessees, have read This chapter and have sufficient knowledge in the operation and maintenance of underground storage tank systems. Name of owner or owner's authorized representative (print): Title: �� r : J - Date: 09' Signature: Tank Contractor I certify that all work was performed as specified by the manufacturer's instructions; that all work was performed according to the applicable codes of practice in Minn. R. ch. 7150_0205; that all work was performed according to applicable state and federal regulations, including this chapter, and that i am in compliance with contractor certification requirements imposed by Minn. R. ch. 7105. Licensed tank supervisor on site during tank work (print): True: ° Signatu re: "i�`�J7! 5+ 1 1 Vales Date: 0 5 MPCA Supervisor#: Licensed Tank contractor or authorized representative (print): Date: S -4 5 MPCA Contractor #: www.pca.state.mn.us - 651- 296 -6300 • 800 -657 -3864 • TTY 651- 282 -5332 or 800 -657 -3864 • Available in alternative formats t -u5 -04 • 1213/08 Page 3 of 5 RESIDENT / OWNER Name: -�,..e,C 'Kies Phone: Address / City / Zip: CONTRACTOR Name: PL License s: & /S Address: L it° ( (' CIO 9 4.-P .ti-j'— City: 7,- (4--4-4 State: ,IL.i/ Zip: C. S V° Phone: 9(g— 3 ,1 3 -3 3 (..) Contact Person: __.- TYPE OF WORK New Replacement Additional Alteration Demolition Description of work: Rei e . ( 0 f1 i q Z E (u s-r) NOTE: Both roof mounted and ground mounted mechanical equipment is required to be screened by City Code. Please contact the Mechanical inspector or one of the Planners for information on permitted screening methods. PERMIT TYPE RESIDENTIAL Fume COMMERCIAL Nero Construction Interior Improvement Install Piping Processed Air Conditioner Exterior HVAC Unit Air Exchanger ground Tank ( InstaflJ erove) Heat Pump installing/removing tank(s), cal for inspection by Fire Marshal and Plumbing Inspector Other RESIDENTIAL FEES: $50.50 Minimum Add-on or alteration to an existing unit (includes $.50 State Surcharge) out appliances, ductwork, etc.) (includes $.50 State Surcharge) $ TOTAL FEE $90.50 Fire repair (replace burned COMMERCIAL FEES: $70.50 Underground tank $50.50 Minimum (includes installation/removal OR State Surcharge) surcharge is $.50. increases by $.50 for each - $2,000 Permit Fee requires a $1.00 surcharge). Contract Value $ x 1% = $ Permit Fee - If Permit Fee is less than $1,000, = $ State Surcharge - If Permit Fee is > $1,000, surcharge $1,000 Permit Fee (i.e. a $1,001 $ TOTAL FEE City of Eap 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 For Office Use Permit #: Permit Fee: Date Received: Staff: J 2009 MECHANICAL PERMIT APPLICATION Date: 4 6 - .2( .. �, / Site Address: 33go "Dodd t? J t rkj 4i f /kw. Tenant: Suite #: I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and taxies of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a perm; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. Applicant's Printed Name FOR OFFICE USE Reviewed By: Date: Required Inspections: Under Ground — Rough In Air Test Gas Service Test _In -floor Heat _Final - Exterior HVAC Screening Inspection EAGAN, :1N. 55122 -18113 651 -675 -5018 Merchant 1 550 08621 ler$ 1[1: 001 (341009506405621001 PhonE Order alicatate t!'Pi V!Jh Total: T AMlfifil 1T1V H. FASJUV it rvd: Online OS Code: NC CC, C'02 Code: !" „H n THANK YOU! Contractor: TPEC 4101 Colorado St Duluth MN 55804 (218) 343 -3312 tr COP: tit II m Cry iU,JV ri 'n tM. J11LiV Total; v 149 Addition: Gopher Eagan Industrial Park 2nd ;pection once tank is removed. - Permit Fee UG Tank ;barge -Fixed Applicant/Permitee: Signature 411 City of Eat - Applicant - $70.00 $0.50 $70.50 Owner: 3380 Dodd LLC 3385 Highway 149 S Eagan MN 55121 Date Issued: 08/21/2009 I hereby acknowledge that I have read this application and state that the of Minnesota Statutes and City of Eagan Ordinances. information is correct and agree to comply with all applicable State 0801.4088 9001.2195 Issued By: Signature Line Net before Adjustments Tare Weights Net Weights Commodities internal 01 3,400 14:22:43 Truck /Trailer: 3,400 Ferrous Torch 230 -1 Ref.No. 3,400 0 3,400 Page: 1/1 Ticket No.: 78555 pis Date: 08/25/2009 Dispatch Ticket: A TANK Container/Bin: 14:22:43 Truck /Trailer: TPEC :R Carrier: 14:22:43 Ref.No. A TANK Date Time Description Weights 08/25/2009 14:01:43 Gross 29,240 08/25/2009 14:22:43 Tare 25,840 08/25/2009 14:22:43 Net 3,400 GREAT WESTERN RECYCLING INDUSTRIES, Inc. Comments: NORTHERN METAL RECYCLING eIY1f Supplier: [800230] TPEC vS Pr sp@ Da& Po ca) User -ID: ckeeha Material Breakdown and Adjustments: Great Western Recycling Industries 521 Barge Channel Road St. Paul, MN 55107 (651) 224 -4871 Great Western Dock & Terminal 1031 Childs Road St. Paul, MN 55106 (651)774 -5931 SCALE TICKET RECEIVING (COPY) HM Gallons Product ,„.... , Product Descri • tion UN1203, GASOLINE, 3, PGII NA1993, FUEL OIL, 3 PGIII UN1268 PETROLEUM PRODUCTS NOS 3 PGIII UN1978, PROPANE, 2.1 ; .. ----..- - USED OIL (NOT REGULATED) Pick-Up Point/Job Site Destination - 1 - The Generator is above named materials GENERATOR NAME (PRINT): SIGNATURE: responsible for the cost of the analysis and disposal of the in compliance with State and Federal regulations. —.) ' - r: ' - — -, TRANSPORTER CERTIFICATION properly classified, packaged, transportation according to the Transportation. TRANSPORTER NAME (PRINT): TRANSPORTER SIGNATURE: - This is to certify the above named materials are marked, labeled, and are in proper condition for applicable regulations of the Department of - -, - - 1- ,-' - i ' & ,./ -; -. _, .. POTENTIAL HAZARDS FIRE OR EXPLOSION Flammable/combuslible material; may be ignited by sparks or flames. Vapors may travel to a source of ignition and flash back. Containers may explode in heat or fire. Vapor explosion hazard indoors, outdoors or in sewers. Runoff to sewer may create fire or explosion hazard. HEALTH HAZARD May be P°iseheus if inhaled or absorbed timu the skin' Vapors tria cause dizziness or suffocation. Contact may irritate of bum skin and eyes. Fire may produce irritating or poisonous gases. Runoff from fire contrd or dilution in water rnay cause pollution. EMERGENCY ACTION Keep unnecessary people away, isolate hazard area and deny entry. Stay upwind and keep out of low areas. Positive pressure self-contained b a (saw an d s f ire fi pro c l o thi ng will provide fimited protection. Isolate for 1/2 mile in all directions if tank, rall car, or truck tank is involved in a fire. CALL FOR EMERGENCY ASSISTANCE: 1. Determan Welding and Tank Service. 763.571.8110 2. Bob Cheney 763.434.5143 5. Gerald Krob 651.429.3439 3. Don Perish 612.7162469 6. Tony Nuss 612.986.1654 4. Dave Axelson....763.300.0642 ff spill or water contamination occurs call: NATIONAL EMERGENCY RESPONSE NO. 1.800.424.8802 FIRE Small fuss: Dry chemicS, CO2, Water spray or reg.der foam. Large fires: Water spray, fog or regular foam. Move container from fie area if you can do so without risk. Apply cooling water to sides of container that are exposed to flames until well after flames are out. Stay away from the ends of the tank. For massive fires in cargo sea, use an unmaned hose holder or monitor nozzles; if this is impossible withdraw from the sea and let fire bum. Withdraw immediately in case of risky sand from venting safety device or any disookration of tad( due to fire. OR LEAK Shut off ignition sorkoes• no flares, smoking, or flames et hazard area Stop leak if you can do it without risk. Water spray may max* vsis; but it may not prevent i in dosed spaces' Small Spills; Take up with sand or other mincombistble absorbent rnatskil and Place in containers for l at er dis Large Spills: Dice far ahead of liquid spill for later chsposaL FIRST AID Move victim to fresh al and call emergency medical care; if not breathing. give artificial respiration ; if breathing is citficult, give oxygen. In case of contact with material, immediately flush eyes with runrity water for at least 15 minutes. Wash skin with soap and watec Remove and isolate contaminated clotting and shoes at site. DETERMAN BROWNIE INC. • 1241 72ND AVE. NE • FRIDLEY, MN 55432 SHIPPING MANIFEST Work Orden Bill To:. WHITE - WORK ORDER Transporter YELLOW - OFFICE COPY Date: PINK - CUSTOMER COPY = DETERMAN BROWNIE INC. • 1241 72ND AVE. NE • FRIDLEY, MN 55432 SHIPPING MANIFEST Work Order: Bill To: HM Gallons Product Description UN1203, GASOLINE, 3, PG II NA1993, FUEL OIL 3, PGIII UN1268 PE i HOLEUM PRODUCTS NOS 3 PGII UN1978, PROPANE, 2.1 USED OIL (NOT REGULATED)) GENERATOR NAME (PRINT): SIGNATURE: Pick-Up Point/Job Site The Generator is responsible for the cost of the analysis and disposal of the above named materialsjn compliance with State and Federal regulations. FIRE OR EXPLOSION Flammable/combustible material; may be ignited by sparks or flames. Vapors may travel to a source of ignition and flash back. Containers may explode in heat or fire. Vapor explosion hazard indoors, outdoors or in sewers. Runoff to sewer may create fire or explosion hazard. HEALTH HAZARD May be poisonous if inhaled or absorbed through the skirt Vapors may cause dizziness or suffocation. Contact may irritate of burn skin and eyes. Fire may produce irritating or poisonous gases. Runoff from fire control or dilution in water may cause pollution. EMERGENCY ACTION Keep unnecessary people away; isolate hazard area and deny entry. Stay upwind and keep out of low areas. Positive pressure self-contained breathing apparatus (SCBA) and structural fire fighter's protective clothing wiH provide limited protection. Isolate for 1/2 mile in all directions if tank, rail car, or truck tank is involved in a fire- CALL FOR EMERGENCY ASSISTANCE 1. Deterrnan Welding and Tank Service 763.571.8110 2. Bob Cheney 763.434.5143 5. Gerald Krob ------- 651.429.3439 3. Don Perish 612.7162469 6. Tony Nuss 612.986.1654 4. Dave Axelson....763.300.0642 If spill or water contamination OCCINS call: NATIONAL EMERGENCY RESPONSE NO. 1.e00424.8802 Transporter. DETERMAN BROWNIE INC. 1241 72ND AVE. N.E. MINNEAPOLIS, MN 55432 POTENTIAL HAZARDS WHITE - WORK ORDER YELLOW - OFFICE COPY Destination DETERMAN BROWNIE INC. 1241 72ND AVE. N.E. MINNEAPOLIS, MN 55432 Date: TRANSPORTER CERTIFICATION - This is to certify the above named materials are properly classified, packaged, marked, labeled, and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. TRANSPORTER NAME (PRINT): TRANSPORTER SIGNATURE FIRE Small fires : Dry chemical, CO2, Water spray or regilar foam. Large fires: Water spray, fog or regular foam, Move contathar from fwe area if you can do so without risk. Apply cooling water to sides of container that are exposed to flames until well after flames are out. Stay away from the ends of the tank. For massive fires in cargo area, we an trimanned hose holder or monitor nozzles; if this is impossible, withicfraw from the anaa and let fire bum. Mildew immediately in case of rising sound from venting safety device or any discoloration of tank due to fwe. SPILL OR LEAK Shut oft ignifion sources; no flares, smokincj, or flames m hazard area. Stop leak if you can do it without risk. Water spray may reduce vapor ; but it may not prevent ignition in closed spaces. Stroll Spills; Take up with sand or other noncombustibka absorbent material and place in containers for later disposal. Large Spills: Dike far ahead of liquid spil for later ichsposal. FIRST AID Move victim to fresh air and call emergency medical care; if not breathing, give artificial respiration; if breathing is dffficult, give oxygen. In case of contact with material, immediately flush eyes with terming water for at least 15 mhutes. Wash skin with soap and water. Remove and isolate contaminated dothing and shoes at site. PINK - CUSTOMER COPY x =��'