"Vapor Recovery System Construction/Operating Permit Application" - Saint Louis County, Missouri

Vapor Recovery System Construction/Operating Permit Application is a legal document that was released by the Health Department - St. Louis County, Missouri - a government authority operating within Missouri. The form may be used strictly within Saint Louis County.

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Saint Louis C
County
OFFICE
USE ONLY
Health Depar
rtment
CH
HECK NO
CHECK RECEIV
VED
/
/
Air Pollution
n Control Prog
gram
CH
HECK AMOUNT
CHECK DATE
6121 North H
Hanley Road
$
/
/
Berkeley, MO
O 63134
F C
CODE
(314) 615-89
924
VAPO
OR RECOVE
ERY SYSTEM
M CONSTRU
UCTION/ O
OPERATING
G PERMIT A
APPLICATIO
ON 
SECTION
N A—Gener
ral Applicatio
on Informati
ion
Facility N
Name
County
Mail (Zip)
Code
Facility S
treet Address
s
City
St
tate
Facility P
hone No.
Facility Con
ntact Person
Co
ontact Person
n’s Phone No.
.
(
)
(
)
Owner’s N
Name
Ow
wner’s Phone
e No.
(
)
Mail (Zip)
Code
Owner’s M
Mailing Addr
ress
City
St
tate
SECTION
N B—Type o
of Applicatio
on (Check all
l appropriate
e boxes)
Op
perating Perm
mit
Initial
Re
enewal
Post C
Construction
Co
onstruction Pe
ermit
New Facility
y
Exist
ting Facility
Brief desc
cription of the
e Planned Con
nstruction:
SECTION
N C—Stage
I Informatio
on
Stage I Sy
ystem Type (S
Specify):
Dual S
System
Coaxial S
System
Vapor Line
Undergro
ound
Manifolded
(Yes or
No)
Tank
ks
Pro
duct Type
Tank Size
e
Tank
k Type
(
(Yes or No)
1
2
3
4
SECTION
N D—Stage
II Informati
on
System:
Ba
alance:
Number of
f Nozzles:
Vacuum A
Assist:
N
Number of Di
ispensers:
Other (Spe
ecify):
Type of Di
ispensers:
D
Dispensers Mo
odel No.:
SECTION
N E—Applic
cant’s Certifi
ication State
ment
“I Certify, ba
sed on the informa
ation and belief fo
rmed after reasona
able inquiry, the st
tatements and info
ormation in this do
ocument are true, a
accurate
and complete
e.”
Signature of R
Responsible Offic
ial of Facility
Date
Type or Print
t Name and Officia
al Title of Signer
Telep
phone
(
)
 
 
Saint Louis C
County
OFFICE
USE ONLY
Health Depar
rtment
CH
HECK NO
CHECK RECEIV
VED
/
/
Air Pollution
n Control Prog
gram
CH
HECK AMOUNT
CHECK DATE
6121 North H
Hanley Road
$
/
/
Berkeley, MO
O 63134
F C
CODE
(314) 615-89
924
VAPO
OR RECOVE
ERY SYSTEM
M CONSTRU
UCTION/ O
OPERATING
G PERMIT A
APPLICATIO
ON 
SECTION
N A—Gener
ral Applicatio
on Informati
ion
Facility N
Name
County
Mail (Zip)
Code
Facility S
treet Address
s
City
St
tate
Facility P
hone No.
Facility Con
ntact Person
Co
ontact Person
n’s Phone No.
.
(
)
(
)
Owner’s N
Name
Ow
wner’s Phone
e No.
(
)
Mail (Zip)
Code
Owner’s M
Mailing Addr
ress
City
St
tate
SECTION
N B—Type o
of Applicatio
on (Check all
l appropriate
e boxes)
Op
perating Perm
mit
Initial
Re
enewal
Post C
Construction
Co
onstruction Pe
ermit
New Facility
y
Exist
ting Facility
Brief desc
cription of the
e Planned Con
nstruction:
SECTION
N C—Stage
I Informatio
on
Stage I Sy
ystem Type (S
Specify):
Dual S
System
Coaxial S
System
Vapor Line
Undergro
ound
Manifolded
(Yes or
No)
Tank
ks
Pro
duct Type
Tank Size
e
Tank
k Type
(
(Yes or No)
1
2
3
4
SECTION
N D—Stage
II Informati
on
System:
Ba
alance:
Number of
f Nozzles:
Vacuum A
Assist:
N
Number of Di
ispensers:
Other (Spe
ecify):
Type of Di
ispensers:
D
Dispensers Mo
odel No.:
SECTION
N E—Applic
cant’s Certifi
ication State
ment
“I Certify, ba
sed on the informa
ation and belief fo
rmed after reasona
able inquiry, the st
tatements and info
ormation in this do
ocument are true, a
accurate
and complete
e.”
Signature of R
Responsible Offic
ial of Facility
Date
Type or Print
t Name and Officia
al Title of Signer
Telep
phone
(
)
 
 
VAPOR RECOVERY OPERATING/CONSTRUCTION PERMITS
This form is to be used for St. Louis County Vapor Recovery System Operating and Construction permits and
Missouri Department of Natural Resources Operating and Construction Permits.
OPERATING PERMIT APPLICATIONS:
MISSOURI STATE OPERATING PERMIT FEES DO NOT APPLY FOR TAX EMEXPT AND
ST. LOUIS COUNTY FACILITIES.
ST. LOUIS COUNTY OPERATING PERMIT FES ARE $100.0 AND APPLY TO NEW FACILITY AND
FACILITIES INCREASING THE NUMBER OF EMISSION POINTS.
Attach the following to your operating permit application:
1. Plumbing diagrams including vapor lines, vent lines, slope of return vapor lines, diameters of all lines,
etc.
2. Proof of underground storage tank registration and any other Missouri State permits that may apply.
CONSTRUCTION PERMIT APPLICATIONS:
MISSOURI STATE CONSTRUCTION PERMIT FEES DO NOT APPLY TO TAX EXEMPT AND
ST. LOUIS COUNTY FACILTIIES.
ST. LOUIS COUNTY CONSTRUCTION PERMIT FEE IS $100.00.
Attach the following to your construction permit application:
1. A complete site diagram and a thorough description of the planned construction.
2. Plumbing diagrams including vapor lines, vent lines, slope of return vapor lines, diameters of all lines,
etc.
3. A list of all equipment being installed and current California Air Resource Board (CARB) and Missouri
Performance Evaluation Test Procedure (MOPETP) executive Order Numbers for the proposed system
and/or the modified system components.
4. Proof of underground storage tank registration and any other Missouri State permits that may apply.
5. Name of contractor performing work.
COMPLETED APPLICATIONS ARE TO BE MAILED TO:
ST. LOUIS COUNTY
HEALTH DEPARTMENT
FISCAL SERVICES
6121 NORTH HANLEY ROAD
BERKELEY, MO 63134
Checks are to be made payable to:
Saint Louis County Treasurer
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