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<br />R:\ll.ItoAn C:C)MMiSSIUN U" Tt:XAS
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<br />" I), 0,,1\"0" 12')li7.{:....iull S.."illll
<br />,~ 11.';11, Tn'... 7K711.2967.
<br />1,,1 Nil,; C,~I:?I ~fi3.Ii9~1
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<br />Sill' ID Nu,
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<br />Phlll No,
<br />(RRC UK Only)
<br />
<br />RAILROAD COMMISSION OF TEXAS
<br />APPLICATION FOR TENTATIVE APPROVAL OF LP.GAS INSTALLATION
<br />
<br />PLEASE TYPE OR PRINT IN lUCK INK FOR MIC~OFILMINC PURPOSES
<br />!
<br />
<br />INSTRUCTIONS TO LICENSEE:
<br />
<br />Plrase re~d Ihe following informalion and answer all ilrms requeued on Corm. If Ihe ilem is nOI applicable 10 your,
<br />inslallalion. mark Ihe box N/A in Ihe right hand column. This fo}m muu be filed prior 10 Lp.gas installation
<br />. conuruclion at schools. hospitals, convalescenl cenlers. licensed relail LPd cylinderfilling and mOlor/mobile fuel servin'~
<br />mllions and !III inslallations of 10,000 waler gallon (w.g.) aggregale c~pacilY or grealer. For installalions 01 less Ihan:.
<br />10,000 w.g. aggregale capacilY, excep' Ihose nOled above.. Ihe LPG Form 501 Complelion Report must'be filed. Relurn:
<br />Ihis lorm to the rderenced address along with all.necessary supplemenlal documents and a S25.oo filing fee payable 10:
<br />Thr Railrolld Commission of Texas - LrG, The refiling fee is S5.oo per resubmillal.
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<br />2
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<br />Licrnnr I\hmr~ , p~ ". r- e "3 a ~ , Trl. No.: ,( '7/3 ) liJ(, 7 - 1/2. 2
<br />Namrorlnm,,'lIio;,:The .boody~d.Y- Tiy-ea",J /fvbb-er- ('d).
<br />~~~i~~~:II~~:~ss /3 '1'1/ i3a.'1 a~er;.. Blvd, City: f1A s",-deAlCl...
<br />7 7 Sf)'? Trl. No.: ( 7/3) 1./7'1- ()tJ/7
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<br />..
<br />
<br />S,a,r:
<br />
<br />IX.
<br />
<br />Zip:
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<br />5 Phy.ical Addrrsa: 13 4'Lj I f3~v a.... eC<.. B/lld Counly: /larris
<br />
<br />6 Nlmr of Inlllllllion Sill' Rrp~ese~llIivr, h -v OS" -, 7/~ ) 1./7~J - {)017 ~
<br />. -ownrr or Operllor afler Complellon: ~ · · T. - '" Tel. No.: ( _ :2 7_
<br />(/flicensed retail LPG operation is involved. insert individual's name a'ld social security number of RRC'
<br />certified owner, "ranch manager or employee in the space iJbove. Constr,=,cfion site represwtatil.es,:,
<br />subcontracfors and consultants must be listed on Page J)
<br />
<br />7 Specify Type of LP.C.. Insllllalion:
<br />
<br />~ C.ommC'rcil. 0
<br />
<br />o S('huol 0
<br />
<br />Bulk Sloragr Only
<br />Cylinckrlilling/MOlor furll
<br />Mobilr Fut'1 Srrvicr Slalion Only
<br />. i ~
<br />
<br />o Bulk Slorlgr Combo Cylindrr'iIIing
<br />o Olht'r TefJ..'(1evan.;
<br />
<br />8 Installalion ProleClion:
<br />
<br />o C.<lnllinrr(sl. frnerd only 0, Containrr(sl prOltcltd by RUllrd paUl only ,
<br />o ("","llinrr(s) npl."lIlinJ: rnd frnCC'd only iii, Conlainrr(sl locllrd ,,'Jlhin pl.'rimelCl' 'rncing. prolrrlrd b~' J:u;l,d rails
<br />o ' C.onlainrr(s)'rncrd with gUlrd paUl tl Oonllinrr(.) prolrelrd by guard rails/vllvr locks only 0 N I A
<br />
<br />9 Type of LP.CI' Dispen.ing.Sy.tern' (or CyJlnderfilling/Molor Fuel/Mobile Fuel 5crYl~~.SI.~on:
<br />
<br />o Pump/Mrler II Tank: 0 Cabinel Displ.'nsrr/MocIel
<br />.0 Rl'moll' Island Dispt'rilrr 0 AUlomllic Displ.'nsrr/MocIcI
<br />
<br />ON/A
<br />
<br />10
<br />
<br />Dispen.ing Sy.lem Prolrclion for Cylinderfilling/MOlor Fuel/Mobile Fuel SerYice SlIllon:
<br />. 0 Fenced '<( 0 Valvr Locks/Gulrd Rails
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<br />11
<br />
<br />Has Company License Been Rtcri"ed for Di.pensing SY'lem?
<br />o Yrs
<br />I-/;"~'" /I Sc.h gO
<br />(E.lIpos,d 'lI"rior or .".i,d yo,dlin, s,u,i/iro/i.on,..
<br />
<br />o No
<br />
<br />,PQ N/A
<br />M N/A
<br />0 N/A
<br />
<br />12
<br />
<br />High Pressure Piping:' Ye 5
<br />lOp"o,in/( P!,JS"" /(r,ol" Ilton '0 psil
<br />
<br />siu',nol"iot Su',nil 1070"'1
<br />
<br />"PC; ....'m !lOll
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<br />(CONTINUED ON lACK)
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<br />X-25
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