Location Approval Form
The submission of this form by a Class III dealer representative does not absolve the dealer of following the rules and regulations established by this Commission concerning the storage of liquefied petroleum gas. Due to the fact that all requisite details are not submitted regarding the storage locations referred to on this this form, it is, therefore assumed when approval is made on the information submitted, details regarding information not provided will comply with all regulations. Any changes to the cylinder location will require a new form to be submitted.
Name of Class III dealer submitting this form: _________________
Name of Dealer supplying gas: _____________________________
Is storage location protected from vehicular impact? ___Yes ___No
Is storage location: _____ inside building or _____ outside building?
Is storage location the proper distance from electrical equipment, ignition sources, doors and windows? _____ Yes _____ No
Is Name of Class III Dealer, Supplier and 24 hour Emergency Contact on storage location? ____Yes ____No Is all the proper signage displayed at storage location? ____Yes ____No
Does the public have access to the cylinder storage location? ____Yes ____No
If yes, please ensure sketch is submitted by properly permitted dealer.
Contact information for someone at cylinder location:
Name ________________________________________________
Telephone Number _____________________________________
Please give brief description of storage area including distances to permanent reference points:
_______________________________________________________
_______________________________________________________
All information submitted on this form has been verified as correct, and it is understood that any changes to this form shall require a new form to be submitted. Signed (person in charge of insuring correctness of this form)
X __________________________________________________
Date: _______________
La. Admin. Code tit. 55, § IX-159