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Naw <br /> San Joaquin Valley Unified Air Pollution Control District <br /> Supplemental Application Form <br /> GASOLINE DISPENSING <br /> This form must be accompanied by a completed Application for Authority to Construct and Permit to Operate form. <br /> PERMIT TO BE ISSUED TO: <br /> LODI UNIFIED SCHOOL DISTRICT <br /> LOCATION WHERE THE EQUIPMENT WILL BE OPERATED: <br /> 820 S. CLUFF AVE. LODI , CA 95240 <br /> CARB EXECUTIVE ORDER CERTIFICATION <br /> Type Executive Order No. <br /> Phase I Phase 1 for Aboveground G- 70-142-B <br /> Phase II G- 70-140-A <br /> PHASE I VAPOR RECOVERY EQUIPMENT DESCRIPTION <br /> Component - Manufacturer Model Number <br /> Fill Adapter -= p T 30 F Alum <br /> Liquid Fill CapP/T 30 W Alum <br /> Vapor Fill Cap OPW 1711 T <br /> Vapor Adapter` OPW 1611 AV <br /> Drop-Tube <br /> Extractor Assembly <br /> Float Vent Valve" <br /> Pressure/Vacuum Relief Valve OPW 523 LIPS 2253 <br /> Overfill Protection I Clay & Batley #1228 - F - 40 <br /> (List Any Add'tronsl Components Regrured) <br /> Please Continue on Reverse Side SA-1 6193 <br />