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San Joaq Valley Unified Air Polluti ontrol District <br />Supplemental Application Form <br />GASOLINE <br />This form must be accompanied by a completed Applfcatfon for Authority to Construct and Permit t <br />rmit to bg Issued to: / a <br />dr <br />Location where the equipm t will be operated: �j' J ,✓ <br />✓'`vc7 Kit➢-r�7 d G J <br />Current Permit to Operate number (if applicable): <br />to form. <br />Instructions <br />1 <br />Complete a separate form for each tank and dispensing system which has a different type of Phase 1 or <br />Phase II vapor recovery system with as much Information as possible. <br />2 <br />Attach a copy of the site pian showing underground fuel and vapor lines and location of dispenser islands. You <br />may submit the drawings in electronic format. <br />Note: Information on Vapor Recovery Executive Orders is available online at: www.arb.ca.gov/vapor/vapor.htm <br />Gasoline Storage Tanks and Nozzles <br />Quantity of <br />Tanks <br />Type of Tanks <br />(Check One for Each Tank) <br />Capacity in Gallons <br />(Indicate if Split Tank) <br />Type and Grade <br />of Fuel <br />/ <br />ffUnderground ❑ Aboveground* <br />ovo <br />j <br />4VUnderground O Aboveground* <br />CVO <br />i <br />❑ Underground ❑ Aboveground* <br />❑ Underground ❑ Aboveground* <br />Total Number of Gasoline Dispensers: <br />Total Number of Gasoline Fueling Points: <br />g <br />(Maximum number of vehicles which can be fueled at one time, <br />normally two vehicles perdispenser <br />Total Number of Gasoline Dispensing Nozzles: <br />(Do not include Diesel) <br />Grades of Gasoline Dispensed per Nozzle: <br />3 <br />Total Number of Vapor Recovery Instruction Signs: <br />Z. (Should be clearly readable from every fueling point) <br />Maximum Facility Gasoline Throughput, <br />7S -v (� Gallons per Month e) Gallons per year <br />Facility Type <br />Retail O Non -Retail <br />*For Aboveground Tanks (includes tanks in underground vaults) <br />Manufacturer: <br />CARB Executive Order Number: <br />PLEASE CONTINUE ON REVERSE 1100 12/02 <br />