Site Closure Form for Permit-By-Rule (PBR) Demolition Debris Disposal Facility Form

Site Closure Form for PBR Demolition Debris Disposal Facility Solid Waste Permit Program Permit-By-Rule (PBR) Doc Type: Permit By Rule

PBR Identification number:

Print or type application. Before submitting your application to the Minnesota Pollution Control Agency (MPCA), make a photocopy for your records. A response letter will be issued.

If your facility is located in the following counties: Submit form and required attachments to:

Northeast Minnesota: MPCA Duluth Office Aitkin, Carlton, Cook, Lake, Itasca, Koochiching, and St. Louis Counties, and 525 Lake Avenue South, Suite 400 Western Lake Superior Sanitary District Duluth, MN 55802 218-723-4660

North Central Minnesota: MPCA Brainerd Office Benton, Cass, Crow Wing, Kanabec, Mille Lacs, Morrison, Pine, Sherburne, 7678 College Road, Suite 105 Stearns, Todd, and Wadena Counties Baxter, MN 56425 218-828-2492

Metro District: Solid Waste Permit Document Coordinator Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, MPCA St. Paul Office Washington and Wright Counties 520 Lafayette Road North St. Paul, MN 55155-4194 651-296-6300 • 800-657-3864

Southeast Minnesota: MPCA Rochester Office Blue Earth, Brown, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, 18 Wood Lake Drive SE Le Sueur, Martin, Mower, Nicollet, Olmsted, Rice, Sibley, Steele, Wabasha, Rochester, MN 55904 Waseca, Watonwan, and Winona Counties 507-285-7343

Southwest Minnesota: MPCA Willmar Office Big Stone, Chippewa, Cottonwood, Jackson, Kandiyohi, Lac Qui Parle, 1601 Highway 12 East, Suite 1 Lincoln, Lyon, McLeod, Meeker, Murray, Nobles, Pipestone, Redwood, Willmar, MN 56201-6002 Renville, Rock, Swift, and Yellow Medicine Counties 320-214-3786

Northwestern Minnesota: MPCA Detroit Lakes Office Beltrami, Becker, Clay, Clearwater, Douglas, Grant, Hubbard, Kittson, Lake of 714 Lake Ave., Suite 220 the Woods, Mahnomen, Marshall, Norman, Otter Tail, Pennington, Polk, Pope, Detroit Lakes, MN 56501 Red Lake, Roseau, Stevens, Traverse, and Wilkin Counties 218-847-1519

Facility name: Permit No.: SW-

I. Effective Dates Date of Permit-by-Rule Notification (mm/dd/yyyy): Date of site closure(mm/dd/yyyy):

II. Facility Information (Please include a map showing location.) A. Facility Location: Facility name: Address: www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats w-sw3-38 • 9/14/12 Page 1 of 3 City: State: Zip: B. Legal description of property (acreage includes the entire area of the facility)

Acres ¼ ¼ ¼ ¼ Section T N R W Township name: County Name: Latitude: Deg Min Sec North Longitude: Deg Min Sec West

C. Responsible Party Information:

Responsible party name: Address: City: State: Zip: Phone: Fax:

III. Operational Information

A. Dates of operation (mm/dd/yyyy): Open: Closed: B. Size of fill area (in square feet): C. Fill volume including cover materials (in cubic yards): D. Average depth of fill: E. Amount of waste type(s) and origin: Wood building demo: Cubic yards Concrete building demo: Cubic yards Road construction demo: Cubic yards Other demo: Cubic yards

IV. Closure Information

A. Yes A Two-foot soil cover capable of sustaining vegetative growth and minimizing erosion has been put in place. B. Yes Proper slopes (minimum 2 percent, maximum 20 percent) have been established. C. Yes A deed notation has been filed with the county and placed with the property deed indicating the site was used as a landfill and identifying the location, amount and type of waste materials disposed. (Attach a copy of the deed notation with the Coutny Recorder’s seal.)

V. Postclosure Information

A. Final use of site after closure:

B. Reminder: The site must be inspected after closure at least once each year between June and September for settlement and corrosion problems. All problems must be corrected within two weeks.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats w-sw3-38 • 9/14/12 Page 2 of 3 V. Signature and Certification I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. I further certify that the construction and operation of the above described facility was in accordance with the conditions of the Minnesota Pollution Control Agency demolition debris disposal permit-by-rule requirements.

Landowner Signature: Date (mm/dd/yyyy): Name: Certification No.: Title: Expiration Date (mm/dd/yyyy): E-mail: Organization: Address: City: State: Zip: Phone: Fax:

Owner (Applicant) Signature: Date (mm/dd/yyyy): Name: Phone: Title: Fax: E-mail: Organization: Address: City: State: Zip:

Operator* Signature: Date (mm/dd/yyyy): Name: Phone: Title: Fax: E-mail: Organization: Address: City: State: Zip: *Provide the same information for other certified operators.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats w-sw3-38 • 9/14/12 Page 3 of 3