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Cility Application for: New Facility Modification Facility Name: Address: Authority to Construct Permit to Operate Contact: Legal Owner: Address: Lat N: Long W: Type of Facility: Retail Vehicle Fuel Type Permit #: Marine Tank Capacity Aircraft Business Fleet # Nozzles Annual Sales (gallons) UL UL+ PUL D2 Other Phase I Vapor Recovery (type): Two-Point CoAxial ARB Executive Order No.: Vent Height (ft): Model: Distance from vent to nearest neighbor (ft).: P/V Valve(s) Ma.

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