STAGE II VAPOR RECOVERY SYSTEM APPLICATION

Application will be processed only if (1) all sections are completed (2) a blue print or site plan along with a materials list and a scope of work for major or minor modifications is included, and (3) the $500 fee is included of major modification or a new installation, (minor modifications will not require a fee).
 

NATURE OF APPLICATION

New installation - no current stage II
Modification of existing stage II vapor recovery system.     Will existing piping be used?
Amendment to existing Authority to Construct - construction not completed
 
 

CONSTRUCTION INFORMATION

Construction start date:      Completion date: 
Construction company name: 
Contact name: 
Phone: 
Email: 
 
 

APPLICANT INFORMATION (as registered with the Corporation Commission)

Corporate/owner name: 
Corporate mailing address: 
City:     State:    Zipcode: 
 
Contact name: 
Phone: 
Email: 
 
Physical facility name: 
Physical Address: 
City:     Zipcode: 
Phone: 
Fax: 
Nature of business:    If other, describe: 
 
 

MAIL OR FAX AUTHORITY TO CONSTRUCT TO

Company name: 
Mailing address: 
City:     State:    Zipcode: 
Fax ATC to you:    Fax: 
Attention: 


DEPARTMENT USE ONLY

 
Date Received: ________________ BMF #:  ________________ ATC Number ________________
 


STAGE I AND STAGE II EQUIPMENT LIST

The equipment list must be completed fully. This list will include all new equipment and existing equipment. Please indicate both the manufacture of the part and the manufactures complete model number.
 

STAGE I INFORMATION:

All stage I systems will consist of 2 point systems that comply with Executive Order G-70-97-A
 
System Type: 
Is remote fill planned:   
Is Two Point system planned:   
Is Coaxial planned:   
    Manufacturer   Model #
Drop tube overfill prevention: 
Liquid Spill Bucket:   
Vapor Spill Bucket:   
Swivel Adapter:   
Tank Monitor System: 
 
Pressure Relief Vent Valves and Vent Pipe:
P/V:   
Vent Pipe Size (inch):     
Vent Pipe Manifolded:     
Vent Pipe Sampling Port:     
Vent Pipe Thru Canopy:     
 
 

STAGE II INFORMATION

System Type: 
 
Hose configuration G-70-52-AM Exhibit:   (exhibit 9c is not allowed in AZ) please (indicate the Exhibit number from G-70-52-AM)
 
    Manufacturer   Model #
Dispenser:   
Nozzle:   
Hose:   
Breakaway:   
Vapor Pot: 
Total # of Dispensers:     # Gas Only:    # Diesel Only:    # Mixed Fuel: 
# of Gasoline Nozzles: 


STORAGE TANKS GASOLINE & DIESEL

(Please provide this information for all tanks existing and new and state the actual tanks capacity)
Grade Capacity Location Position Siphon
Tank		 Vaulted Manifolded Partitioned


FINAL INSTRUCTIONS

In order to process the application in a timely manor please review it and make sure that all the requested information is complete and accurate. If it is not complete this could result in a denial of the application and returning it to you for completion. Make sure that all the requested attachments (Site Plan, Materials List, and Scope of Work), are included. Also make sure that the application is legible this will also help expedite the processing of the application.
 
You are required to build or modify the stage I and or stage II equipment according to this application and drawings. Any deviation not previously approved will result in a failure at the time of the pre-burial inspection and will require you to reschedule the inspection at a later date.

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