DATE: __________________

STAGE I OPERATING PERMIT # _____________________________ ISSUE DATE: _______________
STAGE II PERMIT #: __________________________ ISSUE DATE: ________________________
FACILITY ID#: ___________________ LOCATION: _______________________________________
CITY: _____________________ ZIP: __________

SYSTEM DESCRIPTION: _________________________________________________________
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Party to whom permit was originally issued:

NAME: _____________________________ COMPANY: _________________________________
ADDRESS: _________________________________________________________________________
CITY: _______________________________________ ZIP: ________ PHONE: __________________

I, ____________________________________________, authorized representative of the business or individual listed above, do hereby transfer the above referenced Vapor Recovery permit, copy attached, to the business or individual listed below.

_____________________________________
Signature

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Party to whom permit is transferred:

NAME: _____________________________ COMPANY: _________________________________
ADDRESS: _________________________________________________________________________
CITY: _______________________________________ ZIP: ________ PHONE: __________________

I, ___________________________________________, authorized representative of the business or
individual listed above, do hereby accept the transfer of the above referenced Vapor Recovery permit, including all conditions listed.

______________________________
Signature