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" installationactivityisinvolved. #" # Wastankand/orlinetestingcompletedduringandafterinstallation?&Yes&No 5+C#!%  5 Date(s)Installationactivitiesperformed:0  0%%0%%Contractor(CompanyorFirm):TCEQCRPNo.: $"&%% ̀CRP򀀀 5+-%#(  5 IndividualInstaller/OnSiteSupervisor:TCEQILPNo.:  %x$) Ѐ̀ILP򀀀 ,"'%+  ,8 _ 8_y%_y%Iherebycertifythattheinformationprovidedconcerningrecentinstallationswereconductedbymeorundermydirectsupervision,that 'b&, IamfamiliarwiththeTCEQrequirementsapplicabletosuchactivities,andthattothebestofmyknowledgeandbeliefsuchactivities i(&- wereperformedinconformancewithapplicableTCEQUSTregulations. 0#('.%%  0 0 _ NwwhN30_%_%#N3,Nwt#SignatureofInstaller/Supervisor:NwwhN3%%Q%%% )D(/ Ѐ#N3,Nw{#DzNdyAchN3*k89 wdwd$dd!$(6wa&wa&k,F$ ,k$ ,$ ,w$ +  @++9 9  @#N3ANNdy{#NXQXhN3@ 7.SELFCERTIFICATIONOFCOMPLIANCEWITHUSTREQUIREMENTS}Ԉ PF/9   + P#N3NXQB}#8  N#FhN3Important: CompletionofthissectionisrequiredbeforeTCEQissuesaUSTDeliveryCertificate.DeliveryofregulatedsubstancesintoregulatedUSTs A isprohibitedbystatelawunlessavalid,currentDeliveryCertificateisavailableand/ordisplayedattheUSTfacility. Anyresponsesmarked NO,  oranyincompletesubmittal,willresultinnonissuanceofaDeliveryCertificateforthisfacility. #N3FPN#_~# KA%I%%   K0  NXQXhN3 #N3NXQǀ#0s##IndicateresponsestoeachquestionbymarkingXintheappropriatespaceattheright. N&,%hN3 4*s#s# 4@@#@#K#YES ' '@ % %O%NO :0   :#N3,N&~#NXQXhN3@#N3NXQ#Nz$hN3REGISTRATION#N3$NzԂ#N&,%hN3Ԉ '  '#N3,N&"#ԀNXQXhN3#N3NXQ#0  N#FN3ForregulatedUSTsystemsatthefacilityindicatedbelow,istheregistrationinformationfiledwiththeTCEQ   pursuantto334.7ofTCEQrules(includinginformationinthisfiling)complete,accurate,&uptodate?#N3FN## (j ## (     ," ,NXQXN3@#N3XNXQ|#Nz$N3FACILITY@@FEES#N3$NzЅ#Ԉ ': 'ЀNXQXN3#N3XNXQZ#0  ForregulatedUSTsystemsatthefacilityindicatedbelow,haveallfacilityfeesbilledtodatetothecurrent : ownerbeenpaidinfull(I.e.,annualfeesplusalllatefees,penalties,&interest)?(Doesnotapplyto  commoncarrierrailroads) (x L## (  :  ,": ,NXQXN3  Nz$XNXQFINANCIAL "  ASSURANCE#NXQX$Nz\# '   'PӀ0  N3XNXQForregulatedUSTsystemsatthefacilityindicatedbelow,doesfinancialassurancecoveragemeet "  TCEQrequirements,asdescribedinChapter37SubchapterIofTCEQrules,forfirstpartycorrective   action,thirdpartybodilyinjury,andthirdpartypropertydamageintheeventofapetroleumreleasefrom ` 4  theseUSTsystems?#NXQXN3 # ( ## (  "   ,""  ,  Nz$XNXQTECHNICAL  e  STANDARDS#NXQX$NzE# '(   'Ѐ0  N3XNXQForregulatedUSTsystemsatthefacilityindicatedbelow,areallincompliancewithtechnicalstandards,  e  asdescribedinTCEQrulesin334.49(relatingtoCorrosionProtection),334.50(relatingtoRelease H   Detection),334.51(relatingtoSpillandOverfillPreventionandControl)and334.43(relatingtoVariances  ! andAlternativeProcedures)ifawrittenvariancetoallorpartoftherequirementsofofthepreviousthree X, " sectionshasbeengrantedbytheTCEQ?#NXQXhN3#N3NXQ (A yesrespon#NXQXN3k#N3XNXQseindicatesthatrecordkeepingrequirements  # andreportingdutieshavebeenmetfor60dayspriortoandincludingthedateofcertification.) (pD$## (   e %  e &  NdyAcN3*FGwdwdF$ Fk$ k$ w$ w89wa&wa&,$ +  1'$&$ 1#N3AcNdy#0  N&,%N3 IamcertifyingthatthefollowingUSTsystemsatthisfacilityareincompliance:TankID#(s)_____,_____, $' _____,_____asnumberedonPages4and5ofthisform#N3,%N&0#. N^sK\N3IfcertifyingmoreUSTsystems,pleaselistadditionalID#sonanotherform.#N3K\N^s3#7-+([&[&  7*e:=wdwd$ $FGwa&wa&e,$$ +  <+'( <NXQXN3  8.TANKOWNER/OPERATORSELFCERTIFICATION#N3XNXQ# I?,)   + I0  N N3Iherebycertifyunderpenaltyoflawtothefollowing:*=&=& 0  0s=&=&Iamthe(markone):0s=&s=&&owner...0 =&=&0[ =& =&0 [ =&[ =&0K =& =&&legallyauthorizedrepresentativeoftheowner...J+K =&K =& 0  0s=&=&0s=&s=&0c=&=&0c=&c=&0S=&=&0S=&S=&0C=&=&0C=&C=&03=&=&03=&3=&0#=&=&0#=&#=&0=&=&0=&=&&operator...0K =&=&0 K =&K =&0; =& =&&legallyauthorizedrepresentativeoftheoperator... ,; =&; =& 0  0s=&=&0s=&s=&...oftheregulatedundergroundstoragetank(UST)systemsatthisfacility;ANDH-=&=& 0  0s=&=&IhavepersonallyexaminedandamfamiliarwiththeinformationincludedinSectionsIthroughIVANDVII;AND.s=&s=& 0  0s=&=&Basedonmycurrentknowledgeandunderstanding,thesubmittedinformationistrue,accurate,andcomplete;AND>/s=&s=& 0  0s=&=&Iunderstandthatanypersonwhointentionallyorknowinglysubmitsfalseinformationonthisformissubjecttocriminalprosecution#N3 N#. D:"0s=&s=& DNwwN3 PrintedNameofOwner/Operator(orAuthorizedRepresentative)KK=&Title 󀀀  ԍ c71 Ў#N3wNw#N&,%N3  ;1c71   ;#N3,N&#NwwhN3ԀSignatureofOwner/Operator(OrAuthorizedRepresentative)'=&DateofSignature(pleaseprint)#N3,Nw#N&,%hN3Ԉ c72 Ѐ#N3,N&`#NdyAchN34=&#N3ANNdy#ԀN/hN3򀀀//#N3/XN#NdyAchN3(3  (#N3AcNdyr#NPN3*e5;wdwd$$ $:=wa&wa&e,$$ +  <+'3 <  #N3PN#NXQXN39.TANKOWNER/OPERATORREGISTRATION#N3XNXQ# I?,4   + I0  N N3Iherebyrepresentthefollowing:5=&=& 0  0s=&=& Iamthe(markone):0s=&s=&&owner...0 =&=&0[ =& =&0 [ =&[ =&0K =& =&&legallyauthorizedrepresentativeoftheowner...mA6K =&K =& 0  0s=&=&0s=&s=&0c=&=&0c=&c=&0S=&=&0S=&S=&0C=&=&0C=&C=&03=&=&03=&3=&0#=&=&0#=&#=&0=&=&0=&=&&operator...0K =&=&0 K =&K =&0; =& =&&legallyauthorizedrepresentativeoftheoperator... 7; =&; =& 0  0s=&=&0s=&s=&...oftheregulatedundergroundstoragetank(UST)systemsatthisfacility;ANDk?8=&=& 0  0s=&=&IhavepersonallyexaminedandamfamiliarwiththeinformationincludedinSectionsIthroughIV,andSectionsXXII;AND9s=&s=& 0  0s=&=&Basedonmycurrentknowledgeandunderstanding,thesubmittedinformationistrue,accurate,andcomplete;ANDa5:s=&s=& 0  0s=&=&Iunderstandthatanypersonwhointentionallyorknowinglysubmitsfalseinformationonthisformissubjecttocriminalprosecution.#N3 N֠#Ԁ D:";s=&s=& DNwwN3 PrintedNameofOwner/Operator(orAuthorizedRepresentative)KK=&Title 󀀀  ԍ Z< Ў#N3wNw;#  ;1Z<   ;NwwhN3ԀSignatureofOwner/Operator(OrAuthorizedRepresentative)'=&DateofSignature(pleaseprint)#N3,Nw}#N&,%hN3Ԉ Z= Ѐ#N3,N&<#NdyAchN3WW0=&#N3ANNdy#ԀN/hN3򀀀//#N3/XN#Ԁ 5+> 5N N30  IfyouhavequestionsonhowtofilloutthisformoraboutthePetroleumStorageTankRegistrationandSelfCertificationprogram,pleasecontactusat % ? 512/2392160.Individualsareentitledtorequestandreviewtheirpersonalinformationthattheagencygathersonitsforms.Theymayalsohaveanyerrors  t@ intheirinformationcorrected.Toreviewsuchinformation,contactusat512/2393282.#N3 N#2(&!A=&=&  2G*eIKdwd$$ $5;wa&wa&e,$$ ,A $$ ,$$ ," $$ +  7+"! A!  7  NXQXN310.FINANCIALASSURANCEINFORMATION#N3XNXQ# P=/! B   + PzGFinancialAssurance(PetroleumUSTsonly) "w!C DoesthisfacilitymeetFinancialAssurance(FA)requirementsfor:1stpartycorrectiveaction?&Yes&No 0#"D Ѐ3rdpartybodilyinjury/propertydamageliability?&Yes&No #"E IfYES,identifyFAmechanism(s):&Letterofcredit*&Guarantee*&Trustfund&Financialtest&Insurance(orriskretentiongroup)& J$#F Suretybond*&LocalGov.fin.test**&LocalGov.bondratingtest**&LocalGov.guarantee**&LocalGov.fund ** $#G  0  *0=&=&LetterofCredit,SuretyBond,&Guaranteemethodsmustalsoincludeastandbytrustfund.l%@$H=&=& 0  **0=&=&0=&=&Mechanismsavailableonlyforlocalgovernments(e.g.counties,municipalities,andspecialdistricts). UB+%$I=&=&  U  Informationpertainingtothefinancialassurancemechanism(s)usedtodemonstratefinancialassuranceunderChapter37,SubchapterIof h&<%J Title30,TexasAdministrativeCodeisasfollows: G4*&%K   GNameofIssuer: 's&L  -,('M -AddressofIssuer: -'s&N -Phone#ofIssuer: -'s&O -TypeofMechanismandIdentifying#: ;('s&P  ;Coverageperiod ('Q Beginning:___/____/___ c)7(R Ending: 򀀀 ___/____/___ -)(S - CoverageAmountforCorrective ('T Action c)7(U $ -)(V - CoverageAmountfor ('W ThirdPartyLiability c)7(X $ -)(Y -** ForquestionsregardingFinancial ('Z Assurance,calltheFinancialAssurance k)?([ Sectionat(512)2390300**.$")(\    .NۋShN3   *)\ B Bww , B  **FORASSISTANCEWITHTHISFORM,PLEASEREADTHEINSTRUCTIONSHEET***#N3SNۋ[#  z*)*dd$$ A $$ A $$ " $$ " IKwa&wa&,$$$ +  ,i4'4' , @Nz$N3TCEQFacilityIDNo________________#N3$Nz0# L? NXQXhN3  ӀTCEQUSTREGISTRATION&SELFCERTIFICATIONFORM#N3NXQ# 󀀀  ͻ 4#  i 48  Nz$N3 Important:TheinformationinthefollowingsectionsregardingtheUSTsystem(s)atthisfacilitymustbeproperly  completedinsufficientdetailtosupportregistration.USTowners&operatorsareencouragedtoexaminetheir eX USTrecordsand/orconsultwiththeirUSTequipmentinstallers,servicetechnicians,and/orinsuranceprovidersto    ensurethatthisinformationisaccurateandcomplete. #N3$Nz# R+=" %% ,Rz@' ' NXQXhN311.TANKIDENTIFICATION/DESCRIPTION#N3NXQR#BԈ=&=&Q=&<20   ,  + <*e-.dd$$$ $)*wa&wa&e,$$ ,F$$ ,F$$ ,F$$ ,F$$ +  (    (..ԀTankIdentificationNumbereachtankcompartmentat    yoursiteconsistentwithRule334.8(c)(5)(C). )  ) )  ) )  ) 6#  6 @1'    @ЀTankInstallationDate(Month/day/year) 2#] P  2@"// ;,!] P  ;@.2// ;,!] P  ;@==:x// ?,!] P  ?@""E#// @1'] P    @ЀTankCapacity(inU.S.gallons) )-  ) )-  ) )-  ) --  - 7(-    7Ѐ TankStatus(MarkOneStatus&IndicateDate,if   Applicable)    0  1CurrentlyinUse_R %% 0  2Temporarilyoutofservice(date)  %% 0  MeetsTCEQDefinitionofEmpty?YesorNo %% 0  3Perm.filledinplacew/sand,concrete,etc.(date)aT!%% 0  4Permanentlyremovedfromtheground(date) <-" "%% <1@*& QD %  I'UN32@$___/____/____#N3U I'"#Ԉ  & @$&Yes&No '  I'UN33@$___/____/____#N3U I'#Ԉ OB( 4@$___/____/___ ;,!) ;1@52& QD ,  I'UN32@""/2___/____/____#N3U I'#Ԉ  - @[[/2&Yes&No .  I'UN33@""/2___/____/____#N3U I'#Ԉ OB/ 4@dd/2___/___/____ ;,!0 ;1@<<Ax& QD 3  I'UN32@;x___/____/___#N3U I'#Ԉ  4 @;x&Yes&No 5  I'UN33@;x___/____/___#N3U I'G#Ԉ OB6 4@;x___/____/___ ?,!7 ?1@##L#& QD :  I'UN32@!!F#___/____/____#N3U I'O#Ԉ  ; @!!F#&Yes&No <  I'UN33@!!F#___/____/___#N3U I'#Ԉ OB= 4@""G#___/___/___ I:'>   IЀ Current/LastSubstanceStored (MarkOneSubstance ? percompartment) @ 0  1Gasoline3Kerosene=0A%% 0  2Diesel4UsedOilB%% 0  5NewOilC%% 0  6OtherPetroleumSubstance(specify);.D%% 0  7aCERCLAHazardousSubstance(specify)E%% 0  7bChemicalAbstractService(CAS)No.F%% 0  7cHazardousSubstancesMixture(specify)=0G%% 0  8Petrol./Haz.SubstancesMixture(specify)H%% 0  9Other(specify) E6+I%% E1&3& 1$L 2&4& M 5& xN 6''"k_____________ /"O 7a''"k_____________ P 7b#__________ vQ 7c''"k_____________ - R 8''"k_____________ S 9''"k_____________ ;,!tT ;1&3& 1$W 2&4& X 5& xY 6mm._____________ /"Z 7amm._____________ [ 7b#__________ v\ 7cmm._____________ - ] 8mm._____________ ^ 9mm._____________ ;,!t_ ;1&3& 1$b 2&4& c 5& xd 69 _____________ /"e 7a9 _____________ f 7b#[[; ___________ vg 7c9 _____________ - h 89 _____________ i 99 _____________ ?,!tj ?1&3& 1$m 2&4& n 5& xo 6!!D=&_____________ /"p 7a!!D=&_____________ q 7b#""F=&___________ vr 7c!!D=&_____________ - s 8!!D=&_____________ t 9!!D=&_____________ O+:'tu   $$O   NXQXN312.USTSYSTEMTECHNICALINFORMATION#N3XNXQ#}   wjv q   @1'cVw $$  + @Ѐ Tank&PipingDesign (MarkOneforTank&Piping) UHx 0  1SingleWall y%% 0  2DoubleWallz%% Ѐ ExternalContainment (Markallthatapply) ]P{ 0  3FactoryBuiltNonmetallicJacket|%% 0  4aSyntheticTankPit/PipingTrenchLiner}%% 0  4bTankVault/RigidTrenchLinereX~%% Ѐ TypeofPiping (MarkOne)   0  5aPressurized %% 0  5bSuctionm!`%% 0  5cGravity" %% Ѐ TankInternalProtection  "  0  6InternalTankLining(Indicatedate) 3$"u#h!%% 3Ѐ Tank0 Y )kYkYkPiping  UH 1&,k&   2&,k&  3&,k&  4a&,k&  4b&,k& [N 5aN/A,k&   5bN/A,k& Y!L 5cN/A,k& " 6___/____/___ )W#J! )Ѐ Tank0  5Piping  UH 1&8&   2&8&  3&8&  4a&8&  4b&8& [N 5aN/A8&   5bN/A8& Y!L 5cN/A8& " 6___/____/___ )W#J! )Ѐ Tank0  ++@   Piping  UH 1&+ + C &   2&+ + C &  3&+ + C &  4a&+ + C &  4b&+ + C & [N 5aN/A+ + C &   5bN/A+ + C & Y!L 5cN/A+ + C & " 6___/____/___ -W#J! -Ѐ Tank0 +# q$q$K=&+#=&+#=&Piping  UH 1&q%q%N=&&   2&q%q%N=&&  3&q%q%N=&&  4a&q%q%N=&&  4b&q%q%N=&& [N 5aN/Aq%q%N=&&   5bN/Aq%q%N=&& Y!L 5cN/Aq%q%N=&& "  @ 6___/____/___ B,,1W#J!   B Tank&PipingMaterials (Markallthatapply) E$8" 0  1Steel$"%% 0  2FRP(fiberglassreinforcedplastic)%#%% 0  3Compositetank(steelw/externalFRPcladding)M&@$%% 0  4Concrete&$%% 0  5aJacketed(steelw/externalnonmetallicjacket)'%%% 0  5bCoated(steelw/externalpolyurethanecladding)K(>&%% 0  5cNonmetallicflexiblepiping(&%% 0  5dOther(specify))'%%  PipingConnectors&Valves (Markallthatapply) K*>( 0  6Shear/ImpactValves(underdispenser)*(%% 0  7Steelswingjoints(atendsofpiping)+)%% 0  8Flexibleconnectors(atendsofpiping) G,,6+S,F*%%,, G Tank)kPiping E$8"  1&uu+k& $" 2&uu+k& %# 3&OO*kN/A󀀈 M&@$ 4&uu+k& &$ 5a&uu+k& '% 5b&OO*kN/A󀀈 K(>& 5cN/Auu+k& (& 5d򀀀 )' 6N/Auu+k& *( 7N/Auu+k& +) 8N/Auu+k& =,,,!G,:*,, = Tank5Piping E$8"  1&7& $" 2&7& %# 3&6N/A󀀈 M&@$ 4&7& &$ 5a&7& '% 5b&6N/A󀀈 K(>& 5cN/A7& (& 5d򀀀 )' 6N/A7& *( 7N/A7& +) 8N/A7& =,,,!G,:*,, = Tank++@ Piping  E$8" 1&  B & $" 2&  B & %# 3&A N/A󀀈 M&@$ 4&  B & &$ 5a&  B & '% 5b&A N/A󀀈 K(>& 5cN/A  B & (& 5d򀀀 )' 6N/A  B & *( 7N/A  B & +) 8N/A  B & ?,,,!G,:*,, ? Tankq$q$K=&Piping E$8"  1&G%G%M=&& $" 2&G%G%M=&& %# 3&!%!%L=&N/A󀀈 M&@$ 4&G%G%M=&& &$ 5a&G%G%M=&& '% 5b&!%!%L=&N/A󀀈 K(>& 5cN/AG%G%M=&& (& 5d򀀀 )' 6N/AG%G%M=&& *( 7N/AG%G%M=&& +) 8N/AG%G%M=&&7-+G,:*   ,, 7   -+ *PQdd$$ F$$ FF$$ FF$$ FF$$ F-.wa&wa&,$$$ +  4!   4Ѐ Nz$N3TCEQFacilityIDNo________________ #N3$Nz[# %  NXQXhN3  TCEQUSTREGISTRATION&SELFCERTIFICATIONFORM#N3NXQ#N&,%hN3 @/=&#N3,%N&\#N&,%N3 Y+D,0    ,$Y  #N3,N&#NXQXhN312.USTSYSTEMTECHNICALINFORMATION#N3NXQ#N&,%hN3hԀcontinuedfrompage4:<20  $ ,  + <*eRSdd$$$ $PQwa&wa&e,$$ ,F$$ ,F$$ ,F$$ ,F$$ +  #N3,%N&# 6,'   d6fӀTankIdentification(e.g.,1,2,3,4,etc.) ;,,!+, ; ;,,!+, ; ;,,!+, ; ?,,!+, ? P?,+  d , PЀ Tank/PipingCorrosionProtection (Markallthatapply)   0  1Externaldielectriccoating/laminate/tape/wrap0# %% 0  2aListed/certifiedfactorybuiltcathodicprotection %% 0  2bCertifiedfieldinstalledcathodicprotection`S %% 0  3aListedcompositetank(steelw/FRPexternallaminate) %% 0  3bListedcoatedtank(steelw/externalpolyurethanelaminate) %% 0  4aListedFRPtankorpiping(noncorrodible)( %% 0  4bListednonmetallicflexiblepiping(noncorrodible) %% 0  5aListed/certifiedexternalnonmetallicjacketX K %% 0  5bIsolatedinopenarea(e.g.,sump,boot,etc.) %% 0  6Other(specify) G6+ { %% G Tank)kPiping   1&uu+k& 0# 2a&uu+k&  2b&uu+k& `S 3a&==)kN/A  3b&==)kN/A   4a&uu+k& (  4bN/Auu+k&   5a&uu+k& X K  5b&uu+k&   6򀀀 =,! {  = Tank5Piping   1&7& 0#  2a&7& ! 2b&7& `S" 3a&5N/A # 3b&5N/A  $ 4a&7& ( % 4bN/A7&  & 5a&7& X K ' 5b&7&  ( 6򀀀 =,! { ) = Tank++@ Piping  * 1&  B & 0#+ 2a&  B & , 2b&  B & `S- 3a&@ N/A . 3b&@ N/A  / 4a&  B & ( 0 4bN/A  B &  1 5a&  B & X K 2 5b&  B &  3 6򀀀 ?,! { 4 ? Tankq$q$K=&Piping 5  1&G%G%M=&& 0#6 2a&G%G%M=&& 7 2b&G%G%M=&& `S8 3a&%%K=&N/A 9 3b&%%K=&N/A  : 4a&G%G%M=&& ( ; 4bN/AG%G%M=&&  < 5a&G%G%M=&& X K = 5b&G%G%M=&&  > 6򀀀 K:' { ?   K Tank&PipingReleaseDetection (Markallthatapply) X K @ 0  1Externalvapor/tracermonitoring A%% 0  2Externalgroundwatermonitoring B%% 0  3Monitoringofsecondarycontainmentbarrier) C%% 0  4Automatictankgaugetest&inv.control D%% 0  5Interstitialmonitoringwithinsecondarywall/jacketYLE%% 0  6aMonthlypipingtightnesstest(@0.2gph)F%% 0  6bAnnualpipingtightnesstest(@0.1gph)|G%% 0  6cTriennialtightnesstest(forsuction/gravitypiping)!H%% 0  6dAuto.lineleakdetector(3.0gphforpressurepiping)I%% 0  7aWeeklymanualtankgauging(tanks1,000gal)QDJ%% 0  7bMonthlytankgauging(foremer.generatortanks)K%% 0  8SIRStatisticalInventoryReconciliation&inv.controltL%% 0  9Other(specify)N&,%N3 G6+ M%% G#N3,%N&㌯# Tank)kPiping  X K N 1&uu+k&  O 2&uu+k&  P 3&uu+k& ) Q 4&__*kN/A  R 5&uu+k& YLS 6aN/Auu+k& T 6bN/Auu+k& |U 6cN/Auu+k& !V 6dN/Auu+k& W 7a&__*kN/A QDX 7b&__*kN/A Y 8&uu+k& tZ 9򀀀 =,! [ = Tank5Piping  X K \ 1&7&  ] 2&7&  ^ 3&7& ) _ 4&6N/A  ` 5&7& YLa 6aN/A7& b 6bN/A7& |c 6cN/A7& !d 6dN/A7& e 7a&6N/A QDf 7b&6N/A g 8&7& th 9򀀀 =,! i = Tank++@ Piping  X K j 1&  B &  k 2&  B &  l 3&  B & ) m 4&A N/A  n 5&  B & YLo 6aN/A  B & p 6bN/A  B & |q 6cN/A  B & !r 6dN/A  B & s 7a&A N/A QDt 7b&A N/A u 8&  B & tv 9򀀀 ?,! w ? Tankq$q$K=&Piping  X K x 1&G%G%M=&&  y 2&G%G%M=&&  z 3&G%G%M=&& ) { 4&1%1%L=&N/A  | 5&G%G%M=&& YL} 6aN/AG%G%M=&& ~ 6bN/AG%G%M=&& | 6cN/AG%G%M=&& ! 6dN/AG%G%M=&&  7a&1%1%L=&N/A QD 7b&1%1%L=&N/A  8&G%G%M=&& t 9򀀀 K:'    KЀ SpillContainment&OverfillPreventionEquipment   0  1Tightfillfitting0%%0G%%0G%G%}%% 0  2Factorybuiltspillcontainer/bucket/sump"%% 0  3aDeliveryshutoffvalve(set@95%capacity)%% 0  3bFlowrestrictor,e.g.,ventballfloat(set@90%cap.)RE%% 0  3cAlarm(set@90%),w/3aor3b(set@98%cap.)%% 0  4N/AAlldeliveriestotankare25gal.each G6+u%% G1& t 2& 8+  3a&  3b& h[ 3c&  4& =,! =1& t 2& 8+ 3a&  3b& h[ 3c&  4& =,! =1& t 2& 8+  3a&  3b& h[ 3c&  4& ?,! ?1& t 2& 8+  3a&  3b& h[ 3c&  4&N&,%N3 K:'   K#N3,%N&㌘&#Ԁ Stage1/Stage2VaporRecovery (Markallthatapply) fY l'*0  Seeinstructionsforrule&locationexemptioninformation.%% 0  1StageI (USTtotankertruck):Installationdate:w%% 0  0%%Type:0%%1aStage1twopointsystem%%% 0  0%%0%%0%%0%%0w%%0w%w%0g%% 1bStage1coaxialsystemg%g% 0  0%%Exemptby:0W%%0W%W%1cTCEQRule*UH%%  0  2StageII (vehicletoUST):Installationdate:%% 0  0%%Type:0%%0g%%2aStageIIbalancesystemg%g% 0  0%%0%%0%%0%%0w%%0w%w%0g%%2bStageIIassistsystem&g%g% 0  0%%Exemptby:0W%%0W%W%2cTCEQRule* G6+%% G  I'UN31 !k____/____/____#N3U I',#Ԉ   1a& .!  1b&  1c& ^Q  I'UN32!k____/____/____#N3U I'-#Ԉ  2a&  2b& & 2c& =,! = I'UN31 99-____/____/____#N3U I'.#Ԉ  1a& .! 1b&  1c& ^Q  I'UN3299-____/____/____#N3U I'/#Ԉ  2a&  2b& & 2c& =,! = I'UN31 8 ____/____/____#N3U I'0#Ԉ  1a& .! 1b&  1c& ^Q  I'UN328 ____/____/____#N3U I'Z1#Ԉ  2a&  2b& & 2c& ?,! ? I'UN31 !!C=&____/____/____#N3U I'T2#Ԉ  1a& .! 1b&  1c& ^Q  I'UN32!!C=&____/____/____#N3U I'(3#Ԉ  2a&  2b& & 2c& 7-+    7NۋShN3#N3SNۋ4#NۋShN3***MAKEACOPYOFFORMFORYOURRECORDS***#N3SNۋc4# "  \NXQXhN3 N&,%NXQForSelfCertificationAnnualRenewal, Sections1,2,3,4,7,8,&10 mustbecompleted.Ifthereisachangeof )$" ownershipalongwiththerenewalofthedeliverycertificate, Sections1,2,3,4,7,8,9,10,&11 mustbe $" completed. %# ForRegistrationPurposes, Sections1,2,3,4,9 mustbecompletedand Sections6,10,11,12 shouldbe /'"% completedonlyifapplicable.#NXQX,%N&5# '%  (CR) 󀀀 MarksitemsforinformationthatisneededbyourCentralRegistry.Ifyouhaveanyquestions )s' aboutthesemarkeditems,pleasecalltheTCEQCentralRegistryat512/2395175orgotoourWeb T*G( site(4H#KOO  5  www.TCEQ.state.tx.us)6]8OOq8  7 8Ԁandsearchfor CentralRegistry.