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X X2.FACILITYINFORMATION# X X!  *# *Ԉ UB&6   + U ww X XFacilityName: 7  7-$#8 7 j&, wTypeofFacility: 9 # ww& j>,# Ew w&Retail0  0 % %0%%0u%%0u%u%0e%%&FarmorResidential0 e%e%&WholesaleF9: % % &FleetRefueling0 e &AircraftRefueling0 e%e%0}  % %&IndianLand;} %} % &Indust./Mfg./Chem.Plant0 5 05%5%0%%%&WatercraftFuelingTG<%%%% &Other(specify):  %򀀀# ww E,# j&w w = NumberofregulatedUSTsatthisfacility:# ww& j@/# c.w wԀ򀀀# ww. c/# ?  j&w wNumberofregulatedASTsatthisfacility:# ww& j60# c.w w򀀀# ww. c0#  A  fS7BL    fPhysicalLOCATION: ;.C  4*$D 4 Ew w F3#D    F# ww E1#City:0 O 0OiOi0?ii0?i?i0/ii0/i/i0ii0ii0ii0ii0ii0wii0wiwi0g ii0 g ig i0W i i0 W iW i0G i i0 G iG i07 i iZipCode:07 i7 i0ii0ii0ii0oiiEoioi 0 _ 0_i_i0Oii0OiOi0?ii0?i?i0/ii0/i/i0ii0ii0ii0ii 򀀀TEXAS >4.;.Fii > Ew w F3F    hF# wwh E5#OnSiteContactPerson Ew wԀ# wwh ES6#Title: Ew wԀ# wwh E6#TelephoneNo.: Ew w SFG   ԍ̀# ww E7# & %w wԍ# ww % &7# & %w wԍ/# ww % &8# & %w wԍ󍄎# ww % &a8# & %w wԍ# ww % &8# Ew wԍ  5+%H 5 F3SFI  h  PF# ww E9#E_MAILADDRESS(CR): J  _ F3$/"K FЀFAXNUMBER(CR) L  4*$/"M 4PRIMARYSICCODE(CR)  N SECONDARYSICCODE(CR) F3O  P  PFcounty(cr)  P   ԍ̎  5+%rQ 5PRIMARYNAICSCODE(CR)   R SECONDARYNAICSCODE(CR)  S  B/rT  P  \BLATITUDE(CR)Degrees [NU   ԍ̎  D1"V D  Minutes B/$[NW  B  Seconds -#![NX  -LONGITUDE (CR)  [NY Degrees  ԍ Z Ў   Z   Minutes ![N[  !  Seconds-#![N\   \  -*E dwddd dd 9dd 9rdd rdd wdd wdd Fdd F  wa&wa&,Vdd ,$$ ,$$ , $$ +  @++\ @    ! w wԀ3.C@!1TANKOPERATOR*@V X" !  INFORMATIONA#Vww" V X_@## wwwVw@# <2$] + < A+,!^ AЀ h*w w(markhereifsameasowner)# ww* hB# B MC,_   + MYw2ww w Yxd42wYw* Operatormeansanypersonindaytodaycontrolof,andhavingresponsibilityfor,thedailyoperationoftheASTsystem.#Yw2w4YxdB## ww2wYwB# `  j&w wTCEQOperatorIDNo.:򀀀# ww& jC#(AssignedbyTCEQ) Ew wCustomerNo.:CN򀀀󀀀# ww ED# =3& a   h=TankOperatorName:(DoNotListEmployeesofOperator)  b   ԍ0 _   @  #p!cc #  j&, w TypeofTankOperator:  # ww& jF# g:w wԀ# ww: gF# Ew wԀ&SoleProprietorshipDBA   d  @E&Individual&Corporation&FederalGovt&StateGovt !e &LocalGovt# ww EF# Ew w&CountyGovt&CityGovt " f  &Other(specify):55.=&___________________________________# ww EG# j&w wԈ =#0!g # ww& jH#f  j&w wDatelistedpersonbecameoperator:# ww& j?I# j&w w򀀀/򀀀/򀀀# ww& jI# J@($"j44  h  \JMailingAddress: d"W k   ԍ̎  #" l # 9/L"? l  \  \9City:0 O 0OiOi0?ii0?i?i0/ii0/i/i0ii0ii0ii0ii0ii0wii0wiwiState:0 ii0G i i0 G iG i07 i iZipCode:07 i7 i0ii0ii0ii0oii0oioiCounty:#!mii   ԍ̎  #C$6"n # 9/#!n  \  T9OperatorsAuthorizedRepresentative:0 G 0 G iG iTitle:0' i i0 ' i' i0 i i0ii0iiTelephoneNo.:  ԍ%#oii Ў󍀀󍀀 & %w wԍ# ww % &N# & %w wԍ/򍀀󍄎򍀀# ww % & O#  -#%#oii -'%"o  T   '* wddVdd V$$ $$  $$ Ewa&wa&,$dd +  <+'X&K$oX&K$  < & %w w@II# ww % &P#  ! w w4.REGISTRATIONSTATUS# ww!  :Q# X Xw wQԀ# ww X XQ#Ԉ E;,d&W$p  + E Ew w j& EfӀ # E& jOR#ReasonForSubmittingForm 0 W 0 W %W %(Markallthatapply):T'G%q % % 0 _ 1&InitialRegistration0_%_%0g %%2&ASTOwnershipChange(NewOwnerindicateeffectivedate:)#;%.Qg %g %#______/______/______ '%r 0 _ 3&Amendmentof:0_%_%A&OwnerInformationUpdate0%%0O%%B&FacilityInformationUpdate = EC# E= T#Ԁ&TankInformationUpdatet(g&sO%O% 0 _ 4.&Other(specify):%_%_%$(&t    $ *k(8 dwd$dd $wa&wa&k,$$ +  <+' *'t *'  <    !  E5.OWNERCERTIFICATION# E!  AW#1W @6,* (u   + @  ww EӀIcertifyunderpenaltyoflawthatIhavepersonallyexaminedandamfamiliarwiththeinformationsubmittedinthisandallattacheddocuments,andbased *(v onmyinquiryofthoseindividualsimmediatelyresponsibleforobtainingtheinformation,Ibelievethatthesubmittedinformationistrue,accurate,and A+4)w complete. 1'+)x  81# Ew wW# ww EԀ PrintedNameofOwner/Operator(orAuthorizedRepresentative) =& Title 󀀀 ^,Q*y # Ew wY# ?5,*z  8 B? h*h EӀSignatureofOwner/Operator(OrAuthorizedRepresentative)-=&DateofSignature(pleaseprint) -+{ Ѐ#!#!&=&򀀀//󀀀 :0.,|  B :Ifyouhavequestionsonhowtofilloutthisformoraboutthepetroleumstoragetankregistrationandselfcertificationprogram,pleasecontactus .,} at512/2392160.Individualsareentitledtorequestandreviewtheirpersonalinformationthattheagencygathersonitsforms.Theymayalsohave T/G-~ anyerrorsintheirinformationcorrected.Toreviewsuchinformation,contactusat512/2393282.# E* h[#(/-   (*kfk wdd$$ $(8wa&wa&k,$dd!+  ;i*    ; X X Ef@# E X X#_# j& EԀ TCEQFacilityIDNo________________ 󀀀# E& j_# X X EԀ % Ѐ TCEQASTREGISTRATIONFORM %%P%# E X Xx`#Ԁ<20    i <*e?@dwd$dd!$fkwa&wa&e,N dd ,N dd ,N dd +  =+(   LTd=   X X E 6.TCEQPROGRAMSINWHICHTHISREGULATEDENTITYPARTICIPATES(CR)  na lb# E X Xxb#Notallprogramshavebeenlisted.Pleaseaddtothislistasneeded.Ifyoudontknoworareunsure,pleasemark unknown.b =3,;. T L +d = & % E1# E % &d#ԀAnimalFeedingOperation    & %h E1# E  &d#ԀPetroleumStorageTank    & %h E1# E  &"e#ԀWaterRights    & %h E1# E  &e#ԀTitleVAir    & %h E1# E  & f#ԀWastewaterPermit     & %h E1# E  &f#Ԁ_____________________________     & %h E1# E  &g#ԀIndustrial&HazardousWaste  l _   & %h E1# E  &g#ԀWaterDistricts  l _   & %h E1# E  &g#Ԁ_____________________________ l _    & %h E1# E  &}h#ԀMunicipalSolidWaste  < /   & %h E1# E  &h#󀀀WaterUtilities  < /   & %h E1# E  &ii#ԀUnknown < /    & %h E1# E  &i#ԀNewSourceReviewAir     & %h E1# E  &]j#ԀLicensingType(S)  !     !*:!=d dN dd N N dd N N dd N ?@wa&wa&,udd ,udd +  8+#   X$d8@  X X E TCEQABOVEGROUND(AST)GENERALINFORMATION kԈ 3)'  X$ +d 3# E X Xl#X E _ WhoMustRegister? # EXl#X ERegistrationisrequiredbyTitle30TAC,Chapter , 334,SubchapterF,Section334.123forallabovegroundstoragetanks  (ASTs)thathavebeenusedtostorearegulatedpetroleumproductthatare na inexistenceasofSeptember1,1989,orthatarebroughtintouseafter  September1,1989.ThedeadlineforregisteringexistingtankswasMarch  1,1990.OwnerswhoputtanksintouseafterMarch1,1990mustregister QD theirtankswiththeTexasCommissiononEnvironmentalQualitywithin  30daysfromthedateanyregulatedproductisplacedintothetank.   # EX0m#X E _ WhichTanksAreRegulated? # EX?p#X EASTisdefinedasanonvehicular 4' devicethatismadeofnonearthenmaterials;locatedonorabovethe  surfaceofthegroundoronorabovethesurfaceofthefloorofastructure vi belowground,suchasamineworking,basement,orvault;anddesignedto   containanaccumulationofpetroleum.# EXp#X EOnlyAST'swithacapacitygreater   than1100gallonsareregulated. YL!  _ WhatPetroleumProductsAreRegulated? # EXar#X EPetroleumproductmeansa " productthatisobtainedfromdistillingandprocessingcrudeoilandthatis # capableofbeingusedasafuelforthepropulsionofamotorvehicleor </$ aircraft,including: %  _ 1.motorgasoline;      0 w   0g ww0 g g 0W  0 W W 0G  4.kerosene;# EXIs#X E~q&G G   _ 2.gasohol,andotherblendedfuels;0 0G  5.distillatefueloil;and# EXlu#X E'G G  Ѐ3.aviationgasoline;# EX6v#X E     w    g 0 0W  0 W W 0G  6.diesel#1and#2.# EXv#X E(G G  Ѐ _ Thetermdoesnotincludenaphthatypejetfuel,kerosenetypejetfuel, aT) wasteoil,orapetroleumproductdestinedforuseinchemical * manufacturingorfeedstockofthatmanufacturing. + # EXw#X E0 _ WhichTanksAreExempt? # EXx#X EThefollowingASTsareexemptfrom D 7, regulationunderthisprogram: -__  W(5h83Z"X3"  0 _ X3mz25h  1  .3  0O__  afarmorresidentialASTwithacapacityof1,100gallonsorless !y. usedformotorfuelfornoncommercialpurposes;X3mzz݌'" /OO Ќ  "X3"  0 _ X3{25h  2  .3  0O__  atankusedforstoringheatingoilforconsumptiveuseonthe " 0 premiseswherestored;X3{ |݌i#\!1OO Ќ  "X3"  0 _ X3}25h  3  .3  0O__  aseptictank;X3}P}݌ $!2OO Ќ  "X3"  0 _ X3~25h  4  .3  0O__  asurfaceimpoundment,pit,pond,orlagoon;X3~;~݌$"3OO Ќ  "X3"  0 _ X3 25h  5  .3  0O__  astormwaterorwastewatercollectionsystem;X3 D݌L%?#4OO Ќ  "X3"  0 _ X325h  6  .3  0O__  aflowthroughprocesstank;X3N݌%#5OO Ќ  "X3"  0 _ X325h  7  .3  0O__  atank,liquidtrap,gatheringline,orotherfacilityusedinconnection &$6 withtheexploration,development,orproductionofoil,gas,or /'"%7 geothermalresources,oranyotheractivityregulatedbytheRailroad '%8 CommissionofTexaspursuanttotheNaturalResourcesCode, q(d&9 91.101;# EXYy# X X EX3G݌ )':OO Ќ  XX X X#XXX3#"X3"  ,+LX3׃25h  8  .3  Ԉ0    atransformerorotherelectricalequipmentthatcontainsaregulated ,; substanceandthatisusedinthetransmissionofelectricity,tothe < extentthatsuchatransformerorequipmentisexemptedbythe na= UnitedStatesEnvironmentalProtectionAgencyunder40C.F.R. > Part280;X3׃)݌?%% Ќ  "X3"  ,+LX3(25h  9  .3  Ԉ0    anASTisexemptfromregulationunderthischapterifthesoleor QD@ principalsubstanceinthetankisahazardoussubstance;X3(z݌A%% Ќ  "X3 "  ,*LX325h  10  .3  Ԉ0    aninterstatepipelinefacility,includinggatheringlines,oranAST B connectedtosuchafacilityisexemptfromregulationunderthis 4'C chapterifthepipelinefacilityisregulatedunder:X3݌D%% Ќ  0  0L%%0L%L%(1)theNaturalGasPipelineSafetyActof1968(49UnitedStates viE Code,1671etseq.) F%% 0  0L%%0L%L%(2)theHazardousLiquidPipelineSafetyActof1979(49United G StatesCode,2001etseq.);YLH%% ,*L"X3 "  X3$25h  11  .3  Ԉ0    anintrastatepipelinefacilityorabovegroundstoragetankconnected I tosuchafacilityisexemptfromregulationunderthischapterifthe J pipelinefacilityisregulatedunderoneofthefollowingstatelaws:X3$Q݌</K%% Ќ  0  0L%%0L%L%(1)NaturalResourcesCode,Chapters111and117L%% 0  0L%%0L%L%(2)TexasCivilStatutes,Articles60531and60532;and~qM%% "X3 "  ݀X325h  12  .3  0    anASTthatislocatedatorispartofapetrochemicalplant,a N petroleumrefinery,anelectricgeneratingfacility,orabulkfacility O asthattermisdefinedby26.3574(a)oftheWaterCodeisexempt aTP fromregulationunderthischapterbutisnotexemptforpurposesof Q thefeefordeliveryofcertainpetroleumproductsauthorizedunder R $26.3574oftheWaterCode.# EX啃#X EX3'݌D 7S%% Ќ  ݀  AmendedRegistration:# EX|#X E AnownerofaregulatedASTisrequiredto  T providewrittennoticetotheTCEQofanychangesoradditional !yU informationconcerningthestatusofanyregulatedtank,including,butnot '" V limitedto,operationalstatuscondition,productstored,andownership. " W Whenfilinganamendedregistrationform,pleasemarktheappropriate i#\!X boxinSectionIV.NoticemustbefiledwiththeCommissionwithin30  $!Y daysfromthedateofoccurrenceorknowledgeofthestatuschange. $"Z # EX&#X E  ASTFees :# EXȓ#X EAnannualfeeof$25.00isimposedforeachtankregulated L%?#[ underthisprogram.Feesshallbepaidbytheownerofthetank.Pleasedo %#\ notsendthefeewiththisregistrationform,youwillbesentanannualbill &$] forthefeesowed. /'"%^ # EX&#X E  Penalties: # EX埕#X EAnyownerwhoknowinglyfailstoregistertheirASTsor '%_ submitsfalseinformationmaybesubjecttoacivilpenaltynottoexceed q(d&` $10,000perdayforeachviolation.# EX# X X E )'a  # E X X #  ŗC E# EC ŗn# X EIfyouhavequestionsonhowtofilloutthisformoraboutthePSTprogram,pleasecontactusat512/239-2160. *(b ̀Individualsareentitledtorequestandreviewtheirpersonalinformationthattheagencygathersonitsforms.Theymayalsohaveanyerrorsintheir +)d informationcorrected.Toreviewsuchinformation,contactusat512/239-3282. # EX崗# ŗC E  z,m*e *~AS wddudd uudd u:!=wa&wa&~,$dd!+  ;i*    ;# EC ŗ}# X X E@# E X X# j& EԀ TCEQFacilityIDNo________________ 󀀀# E& j# X X EԀ % Ѐ TCEQASTREGISTRATIONFORM %%P%# E X X#Ԁ<20    i <Gf*e)*dwd$dd!$ASwa&wa&e,$$$ +  ?+*   J$$?G@[ [  X X E7.DESCRIPTIONOFABOVEGROUNDSTORAGETANKS# E X X#ڝԈ=&=&Q=&<20>1 $$ J + <*e-.dd$$$ $)*wa&wa&e,$$ ,F$$ ,F$$ ,F$$ ,F$$ +  (dWdW (..ԀTankID(e.g.1,2,3orA,B,C) )vi ) )vi ) )vi ) 6#vi 6 @1'vi   @ЀTankInstallationDate(Month/day/year) 2#NA  2@"// ;,!NA  ;@.2// ;,!NA  ;@..:x// ?,!NA  ?@t"t"E#// @1'NA    @ЀTankCapacity(U.S.gallons)(mustbe>1100gallons) )& ) )& ) )& ) -& - 7(&   7ЀTankStatus  0  1InUse(includestanksthatareinactivebutcontain  product)f Y%% 0  2OutofUse(tanksthatareinactiveanddonotcontain   product).Indicatedatetakenoutofuse(mo/day/yr). <-" %% <1@*&  2@$___/____/___   @* ;,!  ;1@52&  2@NN/2___/____/___    @2252 ;,! ! ;1@<<Ax& # 2@;x___/____/___  % @xxAx ?,! & ?1@##L#& ( 2@!!F#___/____/___  * @##L# I:' +   IЀProductStoredMarkone  , 0  1GasolineZ M -%% 0  2Diesel  .%% 0  3Kerosene /%% 0  4AlcoholBlendedFuelsvi 0%% 0  5AviationGasoline* 1%% 0  6DistillateFuelOil 2%% 0  7Other(pleasespecify) E6+3%% E1& Z M 5 2&   6 3&  7 4& vi 8 5& * 9 6&  : 7"k_____________ ;,!; ;1& Z M = 2&   > 3&  ? 4& vi @ 5& * A 6&  B 799._____________ ;,!C ;1& Z M E 2&   F 3&  G 4& vi H 5& * I 6&  J 79 _____________ ?,!K ?1& Z M M 2&   N 3&  O 4& vi P 5& * Q 6&  R 7!!D=&_____________ I:'S   IЀMaterialofConstructionMarkone j]T 0  1SteelU%% 0  2FiberglassV%% 0  3AluminumyW%% 0  4CorrugatedMetal:-X%% 0  5ConcreteY%% 0  6Other(pleasespecify) E6+Z%% E1& \ 2& ] 3& y^ 4& :-_ 5& ` 6"k_____________ ;,!a ;1& c 2& d 3& ye 4& :-f 5& g 699._____________ ;,!h ;1& j 2& k 3& yl 4& :-m 5& n 69 _____________ ?,!o ?1& q 2& r 3& ys 4& :-t 5& u 6!!D=&_____________ I:'v   IContainmentMarkallthatapply zmw 0  1EarthenDike.!x%% 0  2ContainmentLinery%% 0  3Concretez%% 0  4NoneJ={%% 0  5Other(pleasespecify) E6+|%% E1& .!~ 2&  3&  4& J= 5"k_____________ ;,! ;1& .! 2&  3&  4& J= 599._____________ ;,! ;1& .! 2&  3&  4& J= 59 _____________ ?,! ?1& .! 2&  3&  4& J= 5!!D=&_____________ K:'   KЀStage1/Stage2VaporRecovery(Markallthatapply)  *0  Seerule&locationexemptioninformation.}%% 0  1StageI(ASTtotankertruck):Installationdate:>1%% 0  0%%Type:0%%1aStage1twopointsystem%% 0  0%%0%%0%%0%%0w%%0w%w%0g%% 1bStage1coaxialsystemg%g% 0  0%%Exemptby:0W%%0W%W%1cTCEQRule*ZM%% 0  2StageII(vehicletoAST):Installationdate:%% 0  0%%Type:0%%0g%%2aStageIIbalancesystemg%g% 0  0%%0%%0%%0%%0w%%0w%w%0g%%2bStageIIassistsystemv ig%g% 0  0%%Exemptby:0W%%0W%W%2cTCEQRule* G6+*!%% G1!k____/____/____ >1 1a&  1b&  1c& ZM 2!k____/____/____  2a&  2b& v i 2c& =,!*! = 1 99-____/____/____ >1  1a&   1b&  1c& ZM 299-____/____/____  2a&  2b& v i 2c& =,!*! = 1 8 ____/____/____ >1 1a&   1b&  1c& ZM 28 ____/____/____  2a&  2b& v i 2c& ?,!*! ? 1 !!C=&____/____/____ >1 1a&  1b&  1c& ZM 2!!C=&____/____/____  2a&  2b& v i 2c&7-+*!    7 CXDFGHIKP(?.p 8 WXh EɅHhX3w sSCxx3*0  StageI/StageIIVaporRecovery# CJHɅ#;ɅHJ CԀPleaseindicatewhetheryoursystemhasStageIand/orStageIIvaporrecoveryequipmentandtheinstallationdateofthe "  equipment.Applicablerequirementsmaybefoundin30TAC,115.221229and115.241249.IfyourASTsystemisnotlocatedinanonattainmentcountyorone X#K! ofthe95coveredattainmentcounties,completionofthissectionisnotnecessary.Foracompletelistofcoveredattainmentcounties,pleasereferto30TAC,115.10. $!a&a& # CJH;Ʌ#"Gir "  ;ɅHJ C0  Gir0sa&a&0sa&sa&0a&a&2?.  1  .3  0Sa&a&  StageI󀄀systemusedtocapturevaporsfromtheASTduringdeliveries.StageIisrequiredinnonattainmentcountiesandinthe95coveredattainment $" countiesifthroughputisgreaterthan125,000gallons.GirZ݌t%g#Sa&Sa& Ќ  # CJH;Ʌ,#"Gir "  ɅHJ C0  GirD0sa&a&0sa&sa&0a&a&2?.  2  .3  0Sa&a&  # CJHɅq#;ɅHJ CStageII󀄀systemusedtocapturevaporsfromvehiclefueltanksduringrefueling.StageIIisrequiredonlyinthe16nonattainmentcounties.Thecounties (&$ are:Brazoria,# CJH;Ʌ\#;ɅHJ CԀChambers,# CJH;Ʌe#;ɅHJ CԀCollin,Dallas,Denton,# CJH;Ʌ#;ɅHJ CԀElPaso,# CJH;Ʌ #;ɅHJ CԀFortBend,# CJH;ɅV#;ɅHJ CԀGalveston,# CJH;Ʌ#;ɅHJ CԀHardin,# CJH;Ʌ#;ɅHJ CԀHarris,# CJH;Ʌ:#;ɅHJ CԀJefferson,# CJH;Ʌ#;ɅHJ CԀLiberty,Montgomery,# CJH;Ʌ#;ɅHJ CԀOrange,Tarrant,# CJH;Ʌ(#;ɅHJ CԀandWaller.#;XH;Ʌ## E;X{#GirD݌&$Sa&Sa& Ќ  X EwwX#XwwN# IfyouhavequestionsonhowtofilloutthisformoraboutthePSTprogram,pleasecontactusat512/239-2160. D(7& ̀Individualsareentitledtorequestandreviewtheirpersonalinformationthattheagencygathersonitsforms.Theymayalsohaveanyerrorsintheir )' informationcorrected.Toreviewsuchinformation,contactusat512/239-3282. # EX/# ww Ewww w `*S( @ ***MAKEACOPYOFFORMFORYOURRECORDS***# wwww]## Ew w>#