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Minnesota Pollution <br />Control Agency <br />520 Lafayette Road North <br />St. Paul, MN 55155-4194 <br />UST Notification of Installation <br />or Change in Status Form <br />Underground Storage Tanks (UST) Program <br />Installation, New Information, Closure, Tanks, Piping, Dispensers <br />Doc Type: Permitting Registration Form <br />Notify the Minnesota Pollution Control Agency (MPCA) within 30 days after bringing tank system into use or making a change in <br />status or information. Keep a copy for your records. Unsigned and incomplete forms will be returned. Guidance on page 4. <br />Questions: Call 651-757-2429 or 1-800-657-3864 during normal business hours. <br />Use this form for: MPCA Use Only <br />• Installation or replacement of tank, piping, or dispensers <br />• Change in information, such as site name, address, owner, <br />or tank contents <br />• Change in tank status <br />Site #: <br />County: <br />Date rec'd: I <br />Ways to notify: <br />• Fax: 651-297-2343 or 651-205-4593, Attn: Joann Henry <br />• Mail: Attn: Joann Henry at above address <br />• E-mail: ioann.henrvestate.mn.us (form must be signed before scanning and e-mailing) <br />Site Information <br />Site name: Sunfish Express <br />Address: 6401 W Hwy 10 <br />City: Ramsey <br />State: MN <br />Site # (if known): 123312 <br />Zip code: 55303 County: Anoka <br />Contact name: Imats PonejRep for Owner) Phone: 512-363-6364 <br />Is this site located on Native American lands? ❑ Yes Z No Is this the initial notification for this site? ❑ Yes ® No <br />Type of facility: ® Service station ❑ Government ❑ Education ❑ Industry/Factory ❑ Auto dealer ❑ Utility <br />❑ Bulk plant ❑ Resort ❑ Office building ❑ Other (specify): <br />Owner Information <br />Name: Sunfish Express <br />Address: 6401 W [-[wy 10 <br />City: Ramsey <br />Contact name: (mats Pone (Rep for Owner) <br />A. Action (Enler date [MM/DD/YYYY] <br />1. Tank number <br />See Guidance — pLage 4 <br />2. Install new tank <br />3. Install new piping <br />4. Install new tank and piping <br />5. Install new dispenser() <br />6. Change site information <br />7. Change owner information <br />8. Change tank information <br />9. Change piping, pump, or <br />dispenser information <br />10. Current tank status <br />See Guidance — page 4 <br />11. If tank has been removed, <br />list tank sludge disposal <br />company and Hazardous <br />Waste Generator ID# <br />State: MN Zip code: 55303 <br />of action under tank number) <br />001 <br />002 <br />Phone. 512-363-6364 <br />003 <br />004 <br />Status: Removed <br />Date: 3/13/2017 <br />Edel Oil Service <br />E PA-M N D-985-742- <br />774 <br />Status: Removed Status: Removed Status: Removed <br />Date: 3/13/2017 Date: 3/13/2017 Date: 3/13/2017 <br />Edel Oil Service <br />E PA-M N D-985-742- <br />774 <br />Edel Oil Service <br />E PA-M N D-985-742- <br />774 <br />Edel Oil Service <br />E PA-M N D-985-742- <br />774 <br />www.pca.state.mn.us 651-296-6300 • 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />t-u5-04 • 6/21/13 Page 1 of 5 <br />