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� Minnesota Pollution Control Agency <br />Environmental Analysis and Outcomes Division <br />Environmental Data Management Unit <br />Michael Smith <br />520 Lafayette Road N <br />St. Paul, MN 55155-4194 <br />, . . . <br />Sfationar�� infernal Combustion Engines, Generator(s): - <br />_._ _. _ <br />_ ' .... ..... . . . . . .. . .. .. . . .. . .. . . . p . . _ . . . . . . _ . . _: " <br />fteport either fuel usa�e ur hours of operation, but do not' list th., same information both ways. <br />,Fuel usage <br />1=uei Type Fuel Burned Units <br />No. 1& 2 disfilate oil, �inits 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 />Natural gas, 2 cycle units cubic feet ��� <br />Hour� nf one�ation <br />Fuel Type <br />Hours of Horse Power <br />Operation Design Capacity <br />PJliscellaneous Fuel Usage, AC Heater: <br />Units <br />horsepower <br />horsepower <br />horsepower <br />Fuel Type Amount Fuel Burned Units <br />Natur� I gas. � cubic feet i") <br />No. 1& 2 disti�ate oil gallons <br />No. 5& 6 residual/waste oil gallons <br />L.iquefiefd petroleum gas gallons <br />Unpaved Ftoads: <br />Round trip miles traveled on Credit Record Keeping <br />unpaved roads ("") Option (circle one) <br />ti � 0% 50% 75% . � <br />��� Natural gas may be identified in cc' (hundred cubic feet), therms, or cubic feet on gas bill. If riatural gas amounts are not in cubic feet, please identify <br />what units you are giving natural gas amounts. <br />�x�� Please do not Report the total vehicle miles traveled. Report the distance of one round-trip only. <br />I certify under penalty of law that this document and all attachments were prepared under my direction or supervised by qualified personnel. The <br />information submitted is, to the best of my knowledge and belief, true, accurate and complete. I understand that the data provided in this document <br />will be used by the MPCA to calculate a fee, which the facility will be required to pay under Minn. R. 7002.0065, based on the tons of pollution emitted by <br />the facility. <br />Sig at Y� Pan Title of Co a Off'cial: <br />�,.. . • � �. . �.���� ��L �� Date <br />�, � <br />Name and Title of Company O ficial (p�ease print): <br />"�— �, � � ,, i / <br />4�� � � r v�-��C� S 6 � r-�, ��ti1 �� �� <br />i � <br />/ <br />�/�c <br />U1Cl�� �` <br />Forms must be received by April 1, please mail us this form with an original signature. A copied or faxed signature is unacceptable. <br />Please contact Michael Smith (651) 757-2733 with any questions. <br />aq-ei3-14 <br />