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. � 1 ` <br /> PUGET SOUND AIIt POLLUTION C:UNTROL AGENCY <br /> �to untoo scYa s�;oe soo s�,w�9e toi-zo3a . <br /> • Telephone:(20�689�035 , <br /> NOTICE OF CONS'TRUCTION AND APPLICATION FOR APPROVAL <br /> Form G <br /> For Gasoline Dbpemtng FscWtla(Iurtractions on Back) • <br /> AGSNCY USE ONLY: DATE RECEIVED RFG NO. . NOC NO. <br /> A pasan who om�be confatAedabout I1tledequlp�o�L Applkmt . �• . � �• <br /> Conua Pason: � . <br /> PLooe Number: ' . <br /> Compmy(or Owna Name): Applicant Addness:� ' <br /> Comp�ny(or Owntt)Mailing Address: , Inshll�iion Addcsss(including Zip Code): <br /> PROJECf DESCRIPTION: • <br /> Snrt D�m: � ' Completion Dete: – <br /> F.«,�„.,�GasoGne • <br /> � '. . .. <br /> New Sntion O Exlsting Starion O Install New Tenla O Iattell Stage 1 O luwlf Snge 2 O <br /> , , _ <br /> STAGE ITTank RetiWng(Gaeoline) t ' <br /> Abave Gmund Tanks ❑ � <br /> Undagtound Tank� O CARB Ordc Number. <br /> Tank Capadry(Gdlnni) Ti�t FTII Mdiod Sit�t/Pma Msrtqfimu�a <br /> Tank N 1 O Dua!Pafnt O Coastal <br /> T�okN2 O DualPo(nt O Coadal <br /> T�ok/3 O DualPalnf O Co�ld • • <br /> T�ok t4 O Dud PoGu' O Coasla! <br /> S'fAGE 2—Veh(de Refheling(Ga+oline) • _ . . <br /> High Hnng .O <br /> Side Mount ❑ Dispmser MCg.: • CARB Otdc Number - ' ' <br /> ChcckOne: � �O{'aeuumAutrt ' � <br /> • ❑ V a Balancs Sy+hn�A(mqlaetunr. . ••.• <br /> Componead Bnnd/Model Com neeb ' � �� BnodlModd <br /> Noa�a: Brcalnary�: ' . <br /> Hoses: . PN Vvver. <br /> d Removal Systan: Retractnn: ' - <br /> SwiveLvElbcw�Fitting�: � • RehoBt Klb: , . <br /> C3eck Valve: O Na;k .. � <br /> O Fsrernd Veeuum Pump: � � � � � <br /> .Fam G 50.I25G(Rcv.Z96)LCV/Sly � � <br />