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San Joaquin *ley Unified Air Pollution C0trol 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 /> I! Permit to be issued to: ! <br /> j ARCO#2076 II <br /> II ! <br /> !i Location where the equipment will be operated: <br /> i <br /> 800 E. Kettleman Ln., Lodi, CA II <br /> n 'I <br /> Current Permit to Operate number(if applicable): <br /> II <br /> Instructions <br /> Complete a separate form for each tank and dispensing system which has a different type of Phase I or <br /> Phase II vapor recovery system with as much information as possible. <br /> 2 <br /> Attach a copy of the site plan showing underground fuel and vapor lines and location of dispenser islands. You <br /> may submit the drawings in electronic format. <br /> i• i i <br /> Note: Information on Vapor Recovery Executive Orders is available online at: www.arb.ca.-gov/vapor/vai)or.htm <br /> Gasoline Storage Tanks and Nozzles <br /> Quantity of Type of Tanks Capacity in Gallons Type and Grade <br /> Tanks (Check One for Each Tank) (Indicate if Split Tank) of Fuel i <br /> li <br /> 4 i ✓ Underground ❑ Aboveground* ; unknown Unleaded gas <br /> II ❑ Underground ❑ Aboveground* I !! <br /> H <br /> ❑ Underground ❑ Aboveground* i i H <br /> ❑ Underground ❑ Aboveground* <br /> H Total Number of Gasoline Dispensers: ! 4 <br /> Total Number of Gasoline Fuelin Points: : 8 (Maximum number of vehicles which can be fueled at one time, <br /> g normally two vehicles per dispenser) <br /> Total Number of Gasoline Dispensing Nozzles: 8 (Do not include Diesel) <br /> #Grades of Gasoline Dispensed per Nozzle: 3 <br /> Total Number of Vapor Recovery Instruction Signs: 8 (Should be clearly readable from every fueling point) <br /> Maximum Facility Gasoline Throughput No change Gallons per Month No change Gallons per year <br /> Facility Type ✓ Retail ❑ Non-Retail <br /> *For Aboveground Tanks (includes tanks in underground vaults) <br /> '� ------- Manufacturer: � _--- --- ------ � !� <br /> I, <br /> CARB Executive Order Number: ' <br /> Of cn cC7 rnrtlTlnu fl-�nnf ocU97DQP cfn7 VM17 <br />