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<br />ABOVEGROUND TANK FACILITY <br />NOTIFICATION FORM <br /> <br />...L A tank <br />X Rove tank <br />- C I ge tank info <br />X C I ge owner <br />C ge add, phone <br />o er <br /> <br />CHECK ONE <br />o FIRST TIME FACILITY REGISTRATION <br />D UPDATED INFORMATION (Check action from table to the right) <br /> <br />TANK LOCATION (SITE ADDRESS) <br />NAME: L W A I INC <br />STREET: <br />CITY <br />COUNTY RAMSEY <br />PHONE ( ) <br />CONTACT PERSON: <br /> <br />ZIP <br /> <br />FACILITY INFORMATION I <br />I <br />TANK OWNER/OPERATOR (MAlLIN ADDRESS) <br /> <br />NAME: Fleet Fuelin Services 0 MN, INC <br />STREET: 1902 W Mi nnehah Ave <br />CITY <br />STATE MN <br />PHONE (61 ) 646-750 <br />CONTACT PERSON: <br /> <br /> <br /> <br /> <br />ZIP I 5104 <br />I <br />I <br /> <br />PLEASE CHECK THE TERM THAT BEST DESCRIBES YOUR FACILITY OPER: TION <br />I <br />I <br />_ SERVICE STATION/BULK FACILITY (34) _ FOOD PROCESSING (49) ; <br />_ CHEMICAL STORAGE (35) _ AGRICULTURAL (1) i <br />'_ INDUSTRY/MANUFACI'URING(19) _ SCHOOL/UNIVERSITY/V01ECH(10)1 <br />_ AUTO CARE',lAUTO PARTS (44) _ ENTERT AINMENTIRADIOrrv /NEW APER (11) <br />_ VEHICLElTRAll.ER DEALER/CAR RENTAL (2) _ HOSPIT AI..JMEDICAL CENTER! <br />_ TRANSPORTATION (37) NURSING HOME/CHll..DREN (17) <br />_ RAll..ROAD (47) _ LANDFll.LIRUBBISH (20) <br />_ UTILITY (39) _ WAS1EWATER/WATER TREATME I .(21) <br />_ CONSTRUCfION (9) _ HOTEL/MOTEL/RESTAURANT ((18) I <br />_ RESIDENTIAL (8) _ MARINA/RESORT/CAMPGROUND/B (23) <br />_ FAMILY FARM (3) _ WASTE OIL STORAGE/RECYCLING 3) <br />_ GOVERNMENT/CITY (12) _ RETAIL STORE (31) <br />_ GOVERNMENT/COUNTY (13) _ BANK/FINANCE/BROKERllNSURAN <br />_ GOVERNMENTISTATE (15) _ CHURCH/CEMETARY/SOCIAL SER <br />_ GOVERNMENTIFEDERAL (14) _ PIPELINE TERMINAL (48) <br />_ GOVERNMENT/INDIAN (16) _ REFINERY (50) <br />OFFICE/MALlJPARKING LOT (40) -X- OTHER (describe) tat <br /> <br />LOADING RACK (FOR TRANSFERS)? Y _ N --X- PAVED? Y -X- N_ CURBED? Y _ N -X- <br /> <br />SPILL RESPONSE PLAN ON SITE? Y -X- N_ <br /> <br /> <br /> <br />IF MORE THAN 10 TANKS ARE AT THIS SITE, PHOTOCOPY THE BACK SIDE OF THIS FORM p. <br />COMPLETION AND INCLUDE AS ADDITIONAL TANK INFORMATION <br /> <br />.... .. <br /> <br /> <br />. .............'.............. <br />. . ...,....,....,.-...-.......... <br /> <br />..,......-...... .,.................... ,....,........ .. <br />......... ..,........'....................................,.......,.,...............-.............. <br />.. .. . . . . .. -...,....,..,........ - . . . . . . . . . . . . . . <br /> <br />.. . .... .'. .' <br /> <br />IF TH.ERE ARE ANY CHANGEs TO THE REPORTED INFORMA TION,THEMPCA MUS'fBEN. i <br />OFTHECHA.NGE IN STATUS WITHIN 30 DAYS OF THE CHANGE. YOU MAY USETlllS~O: <br />, .......,.... INDICATING IN THE UPPER LEFT CORNER THAT IT IS UPDATED rNFORMATION'i.,! <br /> <br />. - - _....... ....._ d_.' <br />. ...-.. . . ..........-......... <br />d. .... ..._..... <br /> <br /> <br /> <br />MPCA Use <br />Owner ill #: <br /> <br />~ <br /> <br />~~41' <br />- F ~ <br /> <br />MINNESOTA POLLUTION <br />CONTROL AGENCY <br /> <br />Site ID #: <br /> <br />This document is available in other fonnalS, <br />including Braille. large print and audio tape. <br />TDD (612) 297-5353 or 1-800-627-3529 <br /> <br />PQ-OOS86-01 <br />APRIL 1993 <br /> <br />o Printed on recycled paper co , ining at least <br />10% fibers from paper recyc! d by consumers <br />