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Agency Use Only
Date
Registration No.
NOC No.
For which of the following actions are you submitting this application:
Stage 1
1. Installation of gasoline storage tanks >1000 gallons capacity
2. Replacement of existing gasoline storage tanks >1000 gallons capacity
3. Replacement of all spill buckets, all drop tubes, or all adaptors
Stage 2
1. Installation of gasoline dispensers (increasing the total number)
2. Replacement of all existing dispensers (including 6-pack to unihose conversions)
3. Removal of the Stage 2 vapor recovery system
Business Information
Facility Name (as it appears on building)
Registration No.
Annual Gasoline Throughput (gal/year)
Facility Address
City
State
Zip Code
Facility Contact Name
Phone Number
Cell Number
Company Name
Email Address
Mailing Address
City
State
Zip Code
Installer Information
Company
Contact
Phone Number
Installation Date
Installation Date
Installers Name (needs ICC vapor recovery certification)
Applicant Information
Company Name
Applicant Name
Mailing Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
I, the undersigned, do hereby certify that the information in this Notification is, to the best of my knowledge, truthful, accurate and complete.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date
Date
You must pay a $500 filing fee to complete this application. Please select an option for payment below.
1. Pay by Check (print a copy of this application and mail with check)
2. Pay by Credit Card (an accounting technician will contact person listed below for payment information)
Contact Person for Credit Card Payment
Contact Phone Number
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Gasoline Dispensing Facility Notification

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