This is a retail dispensing facility YES NO
This facility only fuels marine vessels YES NO
Total proposed gasoline throughput is less than 2,000 gallons per month YES NO
Will the proposed modification cause the tank top to be unburied YES NO
Describe the proposed scope of work:
A. vapor control system
Is the operation exempt from Phase I requirements? YES, please continue at line 12 NO
Is the Phase I system NEW EXISTING
System Name: ARB Executive:
(e.g. Morrison Brothers, OPW, etc.) (e.g. VR-402-B, VR-102-O, etc.)
B. storage TANK (No diesel or waste oil)
Capacity (gallons) / New or Existing? / Aboveground or Underground? / Fuel Type(i.e.gasoline or E85)
Tank # 1
Tank # 2
ABOVEGROUND TANKS (AST) ONLY (For underground storage tanks, continue at line 19):
ARB Standing Loss Control Executive Order:
Standing Loss Control for new tanks VR-302-XX
Standing Loss Control for existing tanks VR-301-XX
AST Manufacturer:
AST Model: AST Serial No:
throughput:
annual: gallons Monthly: gallons
C. FLEET VEHICLE INFORMATION
If you are proposing exemption from Phase II controls based on the number of vehicles equipped with ORVR, please provide a list of all vehicles that can be refueled at this facility including the following information for each vehicle: vehicle's weight, vehicle year, and evaporation family code. Vehicle’s weight is shown as GVWR (Gross Vehicle Weight Rating) and can be found printed on label affixed to driver’s side door jamb. The evaporation family code can be found in the vehicle’s hood or engine compartment or in the applicable ARB Executive Order. This list should not include motorcycles or racing vehicles
Name of Preparer: Title:
Phone No.: E-Mail:
Signature: Date:
NOTE TO APPLICANT:
Before acting on an application for Authority to Construct or Permit to Operate, the District may require further information, plans, or specifications. Forms with insufficient information may be returned to the applicant for completion, which will cause a delay in application processing and may increase processing fees. The applicant should correspond with equipment and material manufacturers to obtain the information requested on this supplemental form.
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