C:\Users\ssunny\Desktop\frmg101_word.doc
This Form is Now Only to be used For Fueling Stations Located at a
Plant
It is not for stand-alone gas dispensing facilities (GDFs)
For stand-alone fuel dispensing systems use the New Technology System
Forms
C:\Users\ssunny\Desktop\frmg101_word.doc
375 Beale Street, Suite 600, San Francisco, CA 94105 GASOLINE DISPENSING
(415) 749-4990 . . . FAX (415) 749-5030 www.baaqmd.gov FACILITY
GDF / Plant No. (if known):
Source No. (if any):
Application No.:
(District Use Only)
Station / Billing Information
Business Name:
Operator Contact:
Site Phone No.
City:
Zip:
If Billing and Renewal should be sent to different address, please enter information below
Billing Site:
Billing Contact:
Alternate Address No.
(District Use Only)
City:
State:
Zip
Billing Phone No.:
If Application is being submitted by an outside agent, please enter the following information
Contractor/Consulting Company:
Contact:
Contact Phone No.:
City:
State:
Zip:
Reason For Application (check all that apply)
Modifying existing site / equipment New Site Violation (list number):
Other (give explanation)
User Type (check all that apply)
Business type (check one)
Vehicle (VEH) Aircraft (AIR) Marine (MAR) Agriculture (AGR)
Retail (REF) Non-retail (NRFE)
Detailed Project Description: (use additional sheet if necessary)
Is this Facility within 1,000 feet of the outer boundary of a school site? Yes No
(Pursuant to Section 25532 and 44321 of the Health and Safety Code)
Equipment Information Must Be Completed In Full. Date of Construction (if NEW, Estimate):
Vapor Recovery Equipment
Current Make and Model
Proposed Make and Model
Phase I *
Phase II **
Product
(please specify)
Make/model of nozzle(s)
Number of single
product nozzles
Number of dual
product nozzles
Number of Triple
product nozzles
Gasoline
Diesel/Kerosene
Revised -4/12/16
FORM G -101B
C:\Users\ssunny\Desktop\frmg101_word.doc
Equipment Information continued (page 2)
Dispenser Information
Current: Make and Model
Qty.
Proposed: Make and Model
Qty.
Highest Annual Throughput for Last 3 years
List Year and Gallons
Proposed Annual Fuel Sales
If Applicable (in gal.)
Tank Information Upon Project Completion
Tank Size (gal)
Product*
Throughput
(Gallons / Month)
Submerged Fill
Pipe? (yes/no)
Submerged Fill - Make and Model
* = 87, 89, 92, Diesel (Die), Kerosene (Ker), E85
Are These Storage Tanks: Underground Aboveground Make and Model:
If Storage Tanks are Aboveground, are Dispenser(s): On Tank Separate (Remote) Location
California Air Resource Board
(CARB) Certified Equipment List
Number
Currently on Site
Number upon
Completion
New Equipment - Make and Model
Spill Containment
Drain Valve Units
Blending Valves
Condensate Traps/pots (Thief
Ports)
Signature Date
Name (Printed) Phone No.
(The above signed accepts full responsibility for fulfillment of Authority to Construct conditions.)
For District Use Only
Date of Last TRS:
Condition No.(s):
Conditioned Throughput:
Previous G#:
Previous A/N:
Final Disposition:
click to sign
signature
click to edit