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� <br />t Minnesota Pollution Control Agency <br />Environmenlal Analysis and Outcomes Division <br />Environmental Data Management Unit <br />Michael Smilh <br />� 520 Lafayette Road N <br />St. Paul, MN 55155-4194 <br />--� <br />� <br />Stationar� fnternal Combustion Engines, Generator(s): <br />Report eithei fuel usage w hours of operation, but do not� list th= same information both ways. <br />Fu>lusage <br />1=uel Type Fuel Burned Units <br />No. 1& 2 distilate cil, unils less than 600 hp gallons <br />No. 1& 2 distilate oil, units greater than 600 hp gallons <br />Natural gas, 4 cycle units cubic feet (�) <br />NaWral gas, 2 cycle uNts cubic feet (�) <br />Hours ot onerauon <br />I Hours of I Horse Power I <br />Fuel Type Operetton Design Capaciry Units <br />horsepower <br />horsepower <br />PJliscellaneous Fuel Usage, AC Heater: <br />Fuel Type � Amount Fuel Burned Units <br />Naturel gas � �, cubic feet ('� <br />Nc. 1 8 2 disti�ate oil gallons <br />No. 5 8 6 residuaVwasle oii gallons <br />l.ique6eld petroleum gas 9allons <br />Unpaved Roads: <br />Round trip miles traveled on Credit Record Keeping <br />unpaved roads ("') Option (circle one) <br />o I -- 0%- 50% 75 % J <br />( � Natural gas may be identiGed in ccf (hundretl cubic feep, therms, or cubic feet on gas bdl. If naWral gas amounis are not in cubic feet, please identify <br />whal units you are giving natural gas amounts. <br />(�Please do not Report the total vehicle miles Iraveled. RepoA ihe distance of one round-irip only. <br />I certity under penalty of law thaUhis document and all attachments were prepared under my direction or supervised by qualified personneL The <br />informalion submitted is, to the besl of my knowledge and belief, true, accurate and complete. I undersland Ihat the data provided in Ihis document <br />will be used by Ihe MPCA to calculate a tee, which lhe facility will be required lo pay under Minn. R. 7002.0065, based on the tons of pollution emitted by <br />the facility. <br />Sig at � n Title �� ��� �ffpcial: � � � � <br />���� C �� <br />7 UI Date: / V <br />, <br />Name and Tille, of Company O icial (p)ease print): <br />---�-- ! I 1 <br />.-. ! �`,C�� � 6ti;1''t'�I Si��i�„Ml�ni� r <br />r <br />Forms must be received by April 1, please mail us this torm with an original signature. A copied or taxed signa[ure is unacceptable. <br />Please contact Michael Smith (651) 757-2733 with any questions. <br />aq-ei3-14 <br />