Attachment III 

Revised Stage II Certification Forms 

Form A: Installation/Substantial Modification Certification 

(Form B: Not included, eliminated as a result of proposed amendments) 

Form C: Annual In-Use Compliance Certification 

Form D 1: Alternative Annual In-Use Compliance Certification (No Testing Required) 

Form D2: Alternative Annual In-Use Compliance Certification (Testing Required) 

Revised Stage II Notification Forms 

FormE: New Stage II System Owner, Operator, Lessee or Controller Notification 

Form F: Stage II System Closure Notification 

For Discussion Purposes Only 
Important: 

When filling out 

forms on the 

computer, use 

only the tab key 

to move your 

cursor- do not 

use the return 

key. 

~ 

~ 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form A 

Installation/Substantial Modification Certification 

A. Stage II System Documentation 

1. Stage II System Location (please print): 

Name of facility where the Stage II System is installed 

Facility address 

City/town 

Telephone number 

Zip code 

2. Stage II System Responsible Official #1 (point of contact for Stage II related correspondence): 

Name of Stage II System Responsible Official (please print) Telephone number 

Mailing address 

City/town State Zip code 

3. Stage II System Responsible Official #2 (fill out only if applicable): 

Name of Stage II System Responsible Official (please print) Telephone number 

Mailing address 

City/town State Zip code 

4. Source of Authority for each Stage II System Responsible Official (RO), as applicable. Please check 

only .Q.!!!t box for each RO. 

If a Corporation, an official with authority to bind the Corporation: 

President 

Secretary 

Treasurer 

R0#1 

0 

0 

0 

R0#2 

0 

0 

0 

If a Partnership, a general partner 

Vice President 

Other person who performs a similar policymaking or decision-making function of the 

Corporation 

If a Sole Proprietorship, the proprietor 

If a municipality/public agency, a principal executive official 

or ranking elected official with authority to enter into contracts 

on behalf of municipality/public agency. 

5. Stage II System Annual Compliance Fee Billing Address.(please print): 

R0#1 

0 

0 

0 

0 

0 

Name of person to whom annual compliance fee is billed Telephone Number 

R0#2 

0 

0 

0 

0 

0 

Name of company Federal Employer 10#- FEIN 

Facility address 

City/town State Zip code 

S2 Form A Summer 2007 Page 1 of 4 
Section B is to 

be completed by 

the Compliance 

Testing 

Company only. 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form A 

Installation/Substantial Modification Certification 

A. Stage II System Documentation (cont.) 

6. Stage II Facility Information: 

a. This form is submitted in response to (check one): 

D The installation of a new Stage II system, where no Stage II system is currently installed. 

D The substantial modification of a currently installed Stage II system. 

b. For an installed Stage II system that has been substantially modified: 

Is any of the Stage II system documentation submitted in 

A.1 - 5 of this form revised from the most recent Stage II 

system documentation submitted to DEP for this facility? 

c. Stage II system Executive Order # of newly 

installed/substantially modified Stage II system: 

d. Fuel dispensed to: 0 private fleet only 

DYes 

D general public 

DNo 

e. How many gasoline storage tanks are associated 

with this Stage II System? Done 0 Two or more 

f. Anticipated amount of gasoline dispensed annually (in gallons): 

0 Less than 120,000 0 120,000 to 240,000 0 240,001 to 500,000 

0 500,001 to 1,000,000 0 1,000,000 to 2,000,000 0 Greater than 2,000,000 

B. Compliance Testing Company Certification 

1. 

Name of Compliance Testing Company (please print) 

2. DEP Stage II Compliance Testing Company 10 #: 

3. Installed Stage II System Executive Order#: 

4. Prior to performing required compliance tests, did you confirm that all above ground Stage II system 

components are installed and are the correct components in accordance with the system's applicable 

Executive Order? 

DYes 0No 

5. For Stage II Systems associated with two or more gasoline storage tanks, prior to performing required 

compliance tests, did you confirm that the gasoline storage tanks are properly manifolded in 

accordance with the system's currently applicable Executive Order? 

D Yes D No D Not Applicable (only one gasoline storage tank) 

6. Are you in compliance with the requirements to perform each applicable compliance test in 

accordance with the referenced test procedure? 

DYes 0No 

S2 Form A Summer 2007 Page 2 of 4 
Section C is to 

be completed by 

Stage II System 

Responsible 

Official(s) only. 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form A 

Installation/Substantial Modification Certification 

B. Compliance Testing Company Certification (cont.) 

7. Date each required installation compliance test was performed and passed: 

a. Pressure Decay test 

b. Vapor Tie test 

c. PN Relief Vent test 

d. Dynamic Back Pressure/Liquid Blockage test 

e. Air/Liquid Volume Ratio Test 

f. Healy Fillneck Pressure test 

g. Healy Vapor Return Line test 

, 

I certify that, (a) I have personally examined the foregoing and am familiar with the information contained 

in Section B. and all attachments that pertain to Section B., and that based on my inquiry of those 

individuals immediately responsible for obtaining the information, I believe that the information is true, 

accurate and complete. I am aware that there are significant penalties for submitting false information, 

including possible fines and imprisonment; and (b) I am fully authorized to make this attestation on behalf 

of this Stage II Compliance Testing Company. 

Printed name of Compliance Testing Co. Responsible 

Official 

Signature of Compliance Testing Co. 

Responsible Official 

C. Stage II Facility Compliance Certification 

Facility Operation, Maintenance and Record Keeping 

Date 

1. Have you obtained and reviewed a copy of your Stage II system's Executive Order and DEP's 

Stage II Facility Training Manual to ensure correct operation and maintenance of your Stage II 

system? 

0 Yes 0 No (If "No", see Directions For Completing Form E, Section C.) 

Stage II System Responsible Official attesting to compliance status 0 #1 0 #2 

2. Are the persons conducting required weekly visual inspections of the Stage II System trained to 

operate and maintain the Stage II system in accordance with the system's applicable Executive 

Order? 

DYes 0No 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

S2 Form A Summer 2007 Page 3 of4 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention -Stage II Vapor Recovery Program 

Stage II Form A 

I nstallation/Su bsta ntial Modification Certification 

C. Stage II Facility Compliance Certification (cont.) 

3. In response to incorrectly installed, non-functioning or broken (broken) Stage II components 

identified as a result of a weekly visual inspection or one or more failed Stage II Compliance 

Tests, are you in compliance with the requirements to: 

i. immediately repair the broken Stage II component; .Q!, if the component can not be 

immediately repaired 

ii. immediately stop dispensing gasoline through the broken component, post "Out of 

Service" signs on it, and repaired it within 14 days; .Q!, if the component can not be 

repaired within 14 days 

iii. immediately isolate the broken component from the remainder of the Stage II system so 

that the Stage II system is correctly operating and post "Out of Service" signs on the 

broken component until repaired; .Q!, if the stage II system can not be isolated from the 

broken component so that the Stage II system is correctly operating 

iv. immediately stop all dispensing of gasoline at the facility and post "Out of Service" 

signs on all gasoline dispensers until the component is repaired, applicable tests 

performed and passed, and a fully completed Annual In-Use Compliance Certification 

submitted to the Department as required. 

DYes D No 

Stage II System Responsible Official attesting to compliance status D#1 D#2 

4. Are you in compliance with the requirements to maintain the following records on-site, in a 

centralized location: 

i. All weekly inspection checklists for the prior twelve-month period identifying incorrectly 

installed, non-functioning or broken components, actions taken to repair the Stage II 

system, and the date of repair. 

ii. A copy of Compliance Testing Company test results for all Stage II Compliance tests 

performed during the prior twelve-month period. 

iii. A copy of the Stage II system's currently applicable DEP Stage II In-Use Compliance 

Certification. 

iv. Record of all persons trained to perform weekly inspections of the Stage II System. 

DYes D No 

I certify that, where I have indicated that I am the Stage II System Responsible Official, (a) I have personally 

examined the foregoing and am familiar with the information contained in this document and all attachments 

and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I 

believe that the information is true, accurate and complete. I am aware that there are significant penalties for 

submitting false information, including possible fines and imprisonment; (b) systems 1 to maintain compliance 

are in place at the facility and will be maintained for the coming year even if the processes or operating 

procedures are changed over the course of the year; and, (c) I am fully authorized to make this attestation on 

behalf of the facility. 

Printed name of Stage II System Responsible Official #1 Signature of Stage II System Responsible Date 

Printed name of Stage II System Responsible Official #2 Signature of Stage II System Responsible Date 

1 For purposes of this statement, "systems to maintain compliance" means procedures that the Stage II facility owner and/or operator has established to 

ensure that weekly visual inspections and required tests are conducted, that broken or defective components are repaired, replaced or isolated and that 

required records are maintained. 

S2 Form A Summer 2007 Page 4 of4 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Customer Code#: 

«FacAccounb> 

Stage II Form C 

Annual In-Use Compliance Ce.rtification 

A. Stage II System Documentation 

1. Stage II System Location 

«RO Name» 

Name of facility where the Stage II System is installed 

«RO Streeb> 

Facility address 

«RO Town» 

City/town 

MA «RO ZIP» 

State Zip code 

2. Stage II System Responsible Official #1 (point of contact for Stage II correspondence) 

«RO MaiiCnb> 

Name of Stage II System Responsible Official 

«RO MailAddr)) 

Mailing address 

«RO _MaiiCity» 

City/town 

«RO _MaiiState» 

3. Stage II System Responsible Official #2 (fill out only if applicable) 

«Dsp0fficiai2Cnb> 

Name of Stage II System Responsible Official 

«Dsp0fficiai2Addr>) 

Mailing address 

«Dsp0fficiai2City» 

City/town 

4. Stage II Annual Compliance Fee Billing Address: 

Name of person to whom annual compliance fee is billed 

Name of company 

Mailing address 

«Dsp0fficiai2Sta 

te» 

«RO Phn>> 

Telephone number 

«RO MaiiZIP» 

Zip code 

«Dsp0fficial2Phone)) 

«Dsp0fficiai2ZIP» 

Telephone Number 

City/town State Zip code 

«CARB_NumCode», «CARB_SysCiass», 5. Stage II System Executive Order#: «CARB_SysType» 

6. DEP records show your facility to dispense __________ gallons of gasoline annually. 

If this is INCORRECT, please check the box below identifying the correct amount of gasoline 

dispensed at your facility (gallons/annually): 

0 Less than 120,000 0 120,000 to 240,000 D 240,001 to 500,000 

0 500,001 to 1,000,000 0 1,000,001 to 2,000,000 

7. How many gasoline storage tanks are associated with 

this Stage II system? 

8. Is the pre-completed Stage II system documentation contained in 

A.1. - 5. correct? 

D Greater than 2,000,001 

Done 0 Two or more 

DYes 0No 

If no, please print the correct information to the right on the same line or check the correct box. 

S2FormC Summer 2007 
6/20/07 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form C 

Annual In-Use Compliance Certification 

Customer Code#: 

«FacAccounb> 

B. In-Use Compliance Testing and Submittal Requirements 

1. In-Use Compliance Tests Required to be Performed and Passed. 

«TestsRequired» 

2. Testing and Submittai Dates 

For this Form to be submitted on time, the envelope used to mail it to DEP must be postmark-dated on or before 

«TestDueDate» AND all compliance tests must be performed and passed within the 30 days prior to the 

postmarked date on the envelope. 

C. Compliance Testing Company Certification 

To be completed by the Compliance Testing Company only 

1. 

Name of Compliance Testing Company (please print) 

2. DEP Stage II Compliance Testing Company ID#: 

3. Prior to performing required compliance tests, did you confirm that all above ground Stage II system components 

are installed and are the correct components in accordance with the system's applicable Executive Order? 

DYes D No 

4. Did you perform each compliance test in accordance with the applicable test procedure? 

DYes D No 

5. For each required compliance test, provide the: 

a. Pressure Decay test 

b. Vapor Tie test 

c. PN Rel ief Vent test 

d. Dynamic Back Pressure/ 

Liquid Blockage test 

e. Air/Liquid Volume Ratio test 

f. Healy Fill-neck Pressure test 

g. Healy Vapor Return Line test 

Date Test First 

Performed 

Result of First 

Test (Pass/Fail) 

Date Test Performed 

and Passed 

6. Were any compliance tests cited in 5. above performed and passed with one or more components isolated from 

the remainder of the Stage II system? 

DYes 0 No 

If yes, please identify the test and isolated component(s): _________________ _ 

I certify that, (a) I have personally examined the foregoing and am familiar with the information contained in Section 

C. and all attachments pertaining to Section C., and that based on my inquiry of those individuals immediately 

responsible for obtaining the information, I believe that the information is true, accurate and complete. I am aware 

that there are significant penalties for submitting false information, including possible fines and imprisonment; and (b) 

I am fully authorized to make this attestation on behalf of this Stage II Compliance Testing Company. 

Printed Name Of Compliance Testing Company 

Responsible Official 

Signature of Compliance Testing Company 

Responsible Official 

Date 

Page 2 of5 
6/20/07 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form C 

Annual In-Use Compliance Certification 

D. Stage II Facility Compliance Certification 

To be completed by the Stage II System Responsible Official(s) only. 

1. Stage II System Operation 

Customer Code#: 

«FacAccount» 

a. Have you operated and maintained the Stage II system in accordance with the system's 

applicable Executive Order? 

DYes D No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status D#1 

b. Have you visually inspected the Stage II system on a weekly basis? 

DYes D No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status D#1 

D#2 

D#2 

c. Are the persons conducting weekly visual inspections trained to operate and maintain the Stage II 

system in accordance with the system's applicable Executive Order? 

DYes 0 No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status D#1 D#2 

2. Stage II System Maintenance 

a. As a result of weekly visual inspections, did you find any Stage II system components incorrectly 

installed, non-functioning or broken (broken)? 

DYes DNo 

If YES, did you: 

i. immediately repair the broken Stage II component; Q!, if the component could not be 

immediately repaired 

ii. immediately stop dispensing gasoline through the broken component, post "Out of 

Service" signs on it, and repaired it within 14 days; Qr, if the component could not be 

repaired within 14 days 

iii. immediately isolate the broken component from the remainder of the Stage II system so 

that the Stage II system is correctly operating and post "Out of Service" signs on the 

broken component until repaired; Qr, if the stage II system could not be isolated from the 

broken component so that the Stage II system is correctly operating 

iv. immediately stop all dispensing of gasoline at the facility and post "Out of Service" signs 

on all gasoline dispensers until the component is repaired, applicable tests performed and 

passed, and a fully completed Annual In-Use Compliance Certification submitted to the 

Department as required. 

DYes D No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status D#1 D#2 

Page 3 of 5 
6/20/07 

Massachusetts Department of Environmental Protection Customer Code#: 

Bureau of Waste Prevention - Stage II Vapor Recovery Program «FacAccount» 

Stage II Form C 

Annual In-Use Compliance Certification 

2. Stage II System Maintenance (cont.) 

b. Was one or more Annual In-Use Compliance test failed on the first try? 

DYes 0 No 

If YES, please check the appropriate box below identifying your response to the failed test(s), 

repairs made, and date repairs completed in order for the Stage II system to pass failed test(s). 

Failed Test Response To Failed Test Repairs And Date Repairs Completed 

(pick one, see details below) In Order For The Stage II System 

To Pass Failed Test(s). 

( 1) (2) (3) (4) (If additional space is needed, use D.4.) 

i. Pressure Decay test 0 0 0 0 

ii. Vapor Tie test 0 0 0 0 

iii. PN Relief Vent test 0 0 0 0 

iv. Dynamic Back Pressure/ 0 0 0 0 Liquid Blockage test 

v. Air/Liquid Volume Ratio 0 0 0 0 test 

vi. Healy Fill-neck Pressure 0 0 0 0 test 

vii. Healy Vapor Return Line 0 0 0 0 test 

(1) immediately repaired the incorrectly installed, non-functioning or broken (broken) Stage II 

component; 2£, if the component could not be immediately repaired 

(2) immediately stopped dispensing gasoline through the broken component, posted "Out of 

Service" signs on it, and repaired it within 14 days; 2£, if the component equid not be 

repaired within 14 days 

(3) immediately isolated the broken component from the remainder of the Stage II system so 

that the Stage II system is correctly operating and posted "Out of Service" signs on the 

broken component until repaired; 2!. if the stage II system could not be isolated from the 

broken component so that the Stage II system is correctly operating 

(4) immediately stopped all dispensing of gasoline at the facility and posted "Out of Service" 

signs on all gasoline dispensers until the component is repaired, applicable tests 

performed and passed, and a fully completed Annual In-Use Compliance Certification 

submitted to the Department as required. 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

3. Stage II System Record Keeping 

Are the following records maintained on-site, in a centralized location: 

a. All weekly inspection checklists for the prior twelve-month period identifying incorrectly installed, nonfunctioning or broken components, actions taken to repair the Stage II system, and the date of repair. 

· b. A copy of Compliance Testing Company test results for all Stage II Compliance tests performed during the 

prior twelve-month period. 

c. A copy of the Stage II system's currently applicable DEP Stage II In-Use Compliance Certification. 

d. Record of all persons trained to perform weekly inspections of the Stage II System. 

0 Yes 0 No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

Page 4 of 5 
6/20/07 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form C 

Annual In-Use Compliance Certification 

4. Compliance Status and Actions to Ensure Future Compliance 

For each question you answered "No" in 0.1 , 2 or 3 above, please explain: 

a. why you answered the question "No"; 

b. the action(s) you took to correct the problem and the date completed; and 

c. the action(s) you took to avoid the problem in the future. 

Please print. If more space is needed, please use additional pages as necessary. 

Customer Code#: 

«FacAccount» 

I certify that (a) I have personally examined the foregoing and am familiar with the information contained in this 

document and all attachments and that, based on my inquiry of those individuals immediately responsible for 

obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are 

significant penalties for submitting false information, including possible fines and imprisonment; (b) systems to 

maintain compliance are in place at the facility and will be maintained for the coming year even if the processes 

or operating procedures are changed over the course of the year; and, (c) I am fully authorized to make this 

attestation on behalf of the facility. 

Printed name of Stage II System Responsible 

Official #1 

Printed name of Stage II System Responsible 

Official #2 

Signature of Stage II System Responsible 

Official #1 

Signature of Stage II System Responsible 

Official #2 

Date 

Date 

Page 5 of 5 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention -Stage II Vapor Recovery Program 

Customer Code#: 

«FacAccountn 

Stage II Form 01 

Alternative Annual In-Use Compliance Certification 

(No In-Use Compliance Testing Required) 

A. Stage II System Documentation 

1. Stage II System Location 

«RO Name» 

Name of facility where the Stage II System is installed 

«RO Street» 

Facility address 

«RO Towm> 

City/town 

MA 

State 

«RO ZIP>> 

Zip code 

2. Stage II System Responsible Official #1 (point of contact for Stage II correspondence) 

«RO MaJICntn 

Name of Stage II System Responsible Official 

«RO MaiiAddn> 

Mailing address 

«RO MaHCity» 

City/town 

«RO _MaiiState» 

3. Stage II System Responsible Official #2 (fill out only if applicable) 

«Dsp0fficiai2Cntn 

Name of Stage II System Responsible Official 

«Dsp0fficiai2Addr» 

Mailing address 

<<Dsp0fficiai2City» 

City/town 

4. Stage II Annual Compliance Fee Billing Address: 

Name of person to whom annual compliance fee is billed 

Name of company 

Mailing address 

ccDspOfficiai2Sta 

te» 

«RO Phm> 

Telephone number 

c<RO MaiJZIP» 

Zip code 

<<Dsp0fficiai2Phone» 

«Dsp0fficiai2ZIP» 

Telephone Number 

City/town State Zip code 

<<CARB_NumCode», «CARB_SysCiass», 5. Stage II System Executive Order#: ccCARB_SysType» 

6. DEP records show your facility to dispense __________ gallons of gasoline annually. 

If this is INCORRECT, please check the box below identifying the correct amount of gasoline 

dispensed at your facility (gallons/annually): 

D Less than 120,000 D 120,000 to 240,000 D 240,001 to 500,000 

D 500,001 to 1,000,000 D 1,000,001 to 2,000,000 

7. How many gasoline storage tanks are associated with 

this Stage II system? 

8. Is the pre-completed Stage II system documentation contained in 

A.1 . - 5. correct? 

D Greater than 2,000,001 

DOne D Two or more 

DYes 0No 

If no, please print the correct information to the right on the same line or check the correct box. 
6/20/07 

Massachusetts Department of Environmental Protection Customer Code#: 

Bureau of Waste Prevention- Stage II Vapor Recovery Program «FacAccounb> 

Stage II Form 01 

Alternative Annual In-Use Compliance Certification 

(No In-Use Compliance Testing Required) 

B. In-Use Compliance Certification Submittal Requirements 

For this Form to be submitted on time, the envelope used to mail it to DEP must be postmark-dated on or before 

«TestDueDate» M'!Q all compliance tests must be performed and passed within the 30 days prior to the 

postmarked date on the envelope. 

C. Stage II Facility Compliance Certification 

To be completed by the Stage II System Responsible Official(s) only. 

1. Stage II System Operation 

a. Have you operated and maintained the Stage II system in accordance with the system's 

applicable Executive Order? 

0 Yes 0 No (if no, see C.4 below) 

Stage II System Responsible Official attesting to compliance status '0 #1 

b. Have you visually inspected the Stage II system on a weekly basis? 

0 Yes 0 No (if no, see C.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 

0#2 

0#2 

c. Are the persons conducting weekly visual inspections trained to operate and maintain the Stage II 

system in accordance with the system's applicable Executive Order? 

0 Yes 0 No (if no, see C.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

2. Stage II System Maintenance 

a. As a result of weekly visual inspections, did you find any Stage II system components incorrectly 

installed, non-functioning or broken (broken)? 

DYes 0 No 

If YES, did you: 

i. immediately repair the broken Stage II component; Q!, if the component could not be 

immediately repaired 

ii. immediately stop dispensing gasoline through the broken component, post "Out of 

Service" signs on it, and repaired it within 14 days; Q!, if the component could not be 

repaired within 14 days 

iii. immediately isolate the broken component from the remainder of the Stage II system so 

that the Stage II system is correctly operating and post "Out of Service" signs on the 

broken component until repaired; Q!, if the stage II system could not be isolated from the 

broken component so that the Stage II system is correctly operating 

iv. immediately stop all dispensing of gasoline at the facility and post "Out of Service" 

signs on all gasoline dispensers until the component is repaired, applicable tests 

performed and passed, and a fully completed Annual In-Use Compliance Certification 

submitted to the Department as required. 

0 Yes 0 No (if no, see C.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

Page 2 of3 
6120107 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form 01 

Alternative Annual In-Use Compliance Certification 

(No In-Use Compliance Testing Required) 

3. Stage II System Record Keeping 

Are the following records maintained on-site, in a centralized location: 

Customer Code#: 

«facAccount» 

a. All weekly inspection checklists for the prior twelve-month period identifying incorrectly installed, nonfunctioning or broken components, actions taken to repair the Stage II system, and the date of repair. 

b. A copy of Compliance Testing Company test results for all Stage II Compliance tests performed during the 

prior twelve-month period. 

c. A copy of the Stage II system's currently applicable DEP Stage II In-Use Compliance Certification. 

d. Record of all persons trained to perform weekly inspections of the Stage II System. 

0 Yes 0 No (if no, see C.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

4. Compliance Status and Actions to Ensure Future Compliance 

For each question you answered "No" in C.1, 2 or 3 above, please explain: 

a. why you answered the question "No"; 

b. the action(s) you took to correct the problem and date completed; and 

c. the action(s) you took to avoid the problem in the future. 

Please print. If more space is needed, please use additional pages as necessary. 

I certify that (a) I have personally examined the foregoing and am familiar with the information contained in this 

document and all attachments and that, based on my inquiry of those individuals immediately responsible for 

obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are 

significant penalties for submitting false information, including possible fines and imprisonment; (b) systems to 

maintain compliance are in place at the facility and will be maintained for the coming year even if the processes 

or operating procedures are changed over the course of the year; and, (c) I am fully authorized to make this 

attestation on behalf of the facility. 

Printed name of Stage II System Responsible 

Official #1 

Printed name of Stage II System Responsible 

Official #2 

Signature of Stage II System Responsible 

Official #1 

Signature of Stage II System Responsible 

Official #2 

Date 

Date 

Page 3 of 3 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention -Stage II Vapor Recovery Program 

Customer Code#: 

«FacAccount» 

Stage II Form 02 

Annual In-Use Compliance Certification 

(In-Use Compliance Testing Required) 

A. Stage II System Documentation 

1. Stage II System Location 

«RO Name» 

Name of facility where the Stage II System is installed 

«RO Street» 

Facility address 

«RO Town» 

City/town 

MA «RO ZIP)) 

State Zip code 

2. Stage II System Responsible Official #1 (point of contact for Stage II correspondence) 

«RO MaiiCnt» 

Name of Stage II System Responsible Official 

<<RO MaiiAddr)) 

Mailing address 

<<RO MaiiCity» 

City/town 

<<RO _MaiiState)) 

3. Stage II System Responsible Official #2 (fill out only if applicable) 

«Dsp0fficiai2Cnb> 

Name of Stage II System Responsible Official 

<<Dsp0fficiai2Addr)) 

Mailing address 

«Dsp0fficiai2City>> 

City/town 

4. Stage II Annual Compliance Fee Billing Address: 

Name of person to whom annual compliance fee is billed 

Name of company 

Mailing address 

<<Dsp0fficiai2Sta 

te)) 

«RO Phn» 

Telephone number 

<<RO MaiiZIP)) 

Zip code 

«Dsp0fficiai2Phone)) 

<<Dsp0fficiai2ZIP)) 

Telephone Number 

City/town State Zip code 

5. Stage II System Executive Order#: <<CARCBA_RNBumSCodTe», <<CARB_SysCiass)), << _ ys ype» 

6. DEP records show your facility to dispense - --------- gallons of gasoline annually. 

If this is INCORRECT, please check the box below identifying the correct amount of gasoline 

dispensed at your facility (gallons/annually): 

0 Less than 120,000 0 120,000 to 240,000 0 240,001 to 500,000 

0 500,001 to 1,000,000 0 1,000,001 to 2,000,000 0 Greater than 2,000,001 

7. How many gasoline storage tanks are associated with 

this Stage II system? · 

8. Is the pre-completed Stage II system documentation contained in 

A.1 . - 5. correct? 

Done 0 Two or more 

DYes 0No 

If no, please print the correct information to the right on the same line or check the correct box. 
6120107 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form 02 

Annual In-Use Compliance Certification 

(In-Use Compliance Testing Required) 

Customer Code#: 

«FacAccounb 

B. In-Use Compliance Testing and Submittal Requirements 

1. In-Use Compliance Tests Required to be Performed and Passed. 

«TestsRequired» 

2. Testing and Submittal Dates 

For this Form to be submitted on time, the envelope used to mail it to DEP must be postmark-dated on or before 

«TestOueDate» AND all compliance tests must be performed and passed within the 30 days prior to the 

postmarked date on the envelope. 

C. Compliance Testing Company Certification 

To be completed by the Compliance Testing Company only 

1. 

Name of Compliance Testing Company (please print) 

2. DEP Stage II Compliance Testing Company ID#: 

3. Prior to performing required compliance tests, did you confirm that all above ground Stage II system components 

are installed and are the correct components in accordance with the system's applicable Executive Order? 

DYes D No 

4. Did you perform each compliance test in accordance with the applicable test procedure? 

DYes D No 

5. For each required compliance test, provide the: 

a. Pressure Decay test 

b. Vapor Tie test 

c. PN Relief Vent test 

d. Dynamic Back Pressure/ 

Liquid Blockage test 

e. Air/Liquid Volume Ratio test 

f. Healy Fill-neck Pressure test 

g. Healy Vapor Retum Line test 

Date Test First 

Performed 

Result of First 

Test (Pass/Fail) 

Date Test Performed 

and Passed 

6. Were any compliance tests cited in 5. above performed and passed with one or more components isolated from 

the remainder of the Stage II system? 

DYes D No 

If yes, please identify the test and isolated component(s): ________________ _ 

I certify that, (a) I have personally examined the foregoing and am familiar with the information contained in Section 

C. and all attachments pertaining to Section C., and that based on my inquiry of those individuals immediately 

responsible for obtaining the information, I believe that the information is true, accurate and complete. I am aware 

that there are significant penalties for submitting false information, including possible fines and imprisonment; and (b) 

I am fully authorized to make this attestation on behalf of this Stage II Compliance Testing Company. 

Printed Name Of Compliance Testing Company 

Responsible Official 

Signature of Compliance Testing Company 

Responsible Official 

Date 

Page 2 of 5 
6/20/07 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form 02 

Annual In-Use Compliance Certification 

(In-Use Compliance Testing Required) 

D. Stage II Facility Compliance Certification 

To be completed by the Stage II System Responsible Official(s) only. 

1. Stage II System Operation 

Customer Code#: 

«FacAccount» 

a. Have you operated and maintained the Stage II system in accordance with the system's 

applicable Executive Order? 

DYes D No (if no, see 0 .4 below) 

Stage II System Responsible Official attesting to compliance status D#1 

b. Have you visually inspected the Stage II system on a weekly basis? 

DYes 0 No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 

D#2 

0#2 

c. Are the persons conducting weekly visual inspections trained to operate and maintain the Stage II 

system in accordance with the system's applicable Executive Order? 

DYes D No (if no, see 0 .4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 D#2 

2. Stage II System Maintenance 

a. As a result of weekly visual inspections, did you find any Stage II system components incorrectly 

installed, non-functioning or broken (broken)? 

DYes 0No 

If YES, did you: 

i. immediately repair the broken Stage II component; .Q!, if the component could not be 

immediately repaired 

ii. immediately stop dispensing gasoline through the broken component, post "Out of 

Service" signs on it, and repaired it within 14 days; Q!, if the component could not be 

repaired within 14 days 

iii. immediately isolate the broken component from the remainder of the Stage II system so 

that the Stage II system is correctly operating and post "Out of Servicen signs on the 

broken component until repaired; .Q!, if the stage II system could not be isolated from the 

broken component so that the Stage II system is correctly operating 

iv. immediately stop all dispensing of gasoline at the facility and post "Out of Service" 

signs on all gasoline dispensers until the component is repaired, applicable tests 

performed and passed, and a fully completed Annual In-Use Compliance Certification 

submitted to the Department as required. 

0 Yes 0 No (if no, see 0 .4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

Page 3 of 5 
6/20/07 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form 02 

Annual In-Use Compliance Certification 

(In-Use Compliance Testing Required) 

2. Stage II System Maintenance (cont.) 

Customer Code#: 

«FacAccount» 

b. Was one or more Annual In-Use Compliance test failed on the first try? 

DYes 0 No 

If YES, please check the appropriate box below identifying your response to the failed test(s), repairs 

made, and date repairs completed in order for the Stage II System to pass the failed test(s). 

Failed Test Response To Failed Test Repairs And Date Repairs Completed 

(pick one, see details below) In Order For The Stage II System 

To Pass Failed Test(s). 

(1) (2) (3) (4) (If additional space is needed, use D.4.) 

i. Pressure Decay test 0 0 0 0 

ii. Vapor Tie test 0 0 0 0 

iii. PN Relief Vent test 0 0 0 0 

iv. Dynamic Back Pressure/ 0 0 0 0 Liquid Blockage test 

v. Air/liquid Volume Ratio 0 0 0 0 test 

vi. Healy Fill-neck Pressure 0 0 0 0 test 

vii. Healy Vapor Return Line 0 0 0 0 test 

(1) immediately repaired the incorrectly installed, non-functioning or broken (broken) Stage II component; 

or, if the component could not be immediately repaired 

(2) immediately stopped dispensing gasoline through the broken component, posted "Out of Service· 

signs on it, and repaired it within 14 days; Q!, if the component could not be repaired within 14 days 

(3) immediately isolated the broken component from the remainder of the Stage II system so that the 

Stage II system is correctly operating and posted "Out of Service" signs on the broken component 

until repaired; Q!, if the stage II system could not be isolated from the broken component so that the 

Stage II system is correctly operating 

(4) immediately stopped~ dispensing of gasoline at the facility and posted "Out of Service· signs on all 

gasoline dispensers until the component is repaired, applicable tests performed and passed, and a 

fully completed Annual In-Use Compliance Certification submitted to the Department as required. 

Stage II System Responsible Official attesting to compliance status 0 #1 0 #2 

3. Stage II System Record Keeping 

Are the following records maintained on-site, in a centralized location: 

a. All weekly inspection checklists for the prior twelve-month period identifying incorrectly installed, nonfunctioning or broken components, actions taken to repair the Stage II system, and the date of repair. 

b. A copy of Compliance Testing Company test results for all Stage II Compliance tests performed during the 

prior twelve-month period. 

c. A copy of the Stage II system's currently applicable DEP Stage II In-Use Compliance Certification. 

d. Record of all persons trained to perform weekly inspections of the Stage II System. 

0 Yes 0 No (if no, see 0.4 below) 

Stage II System Responsible Official attesting to compliance status 0#1 0#2 

Page 4 of 5 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form E 

New Stage II System Owner, Operator, Lessee or 

Controller Notification 

B. Revised Stage II System Documentation (cont.) 

3. Source of Authority for each Stage II System Responsible Official (RO), as applicable. Please check 

only Qlli! box for each RO. 

If a Corporation, an official with authority to bind the Corporation: 

R0#1 R0#2 

President 0 0 Vice President 

Secretary 0 0 Other person who performs a similar policyTreasurer 0 0 making or decision-making function of the 

Corporation 

If a Partnership, a general partner 

If a Sole Proprietorship, the proprietor 

If a municipality/public agency, a principal executive official 

or ranking elected official with authority to enter into contracts 

on behalf of municipality/public agency. 

R0#1 R0#2 

0 0 

0 0 

0 0 

0 0 

0 0 

Important: Please provide the effective date each .!!!!! 

Responsible Official assumed his/her responsibilities, as 

applicable. 

RO #1: _ __...:1_---'/"----

RO #2: __ .:.../ _ ___,/ __ 

4. Stage II Annual Compliance Fee Billing Address 

Has the person, name of the company or the address on record in 

the Department's Stage II database as paying the Stage II Annual 

Compliance Fee, changed? DYes 0No 

If yes, please complete the information below. If no, continue to Section C. 

Stage II Annual Compliance Fee Billing Address: 

Name of person to whom compliance fee shall be billed (please print) 

Name of new company 

Mailing address 

City/town State 

Important: Please provide the effective date the .!!!!! company 

assumed responsibility for paying the Stage II Annual Compliance 

Fee. 

Updated FormE lll.doc • rev. 11/04 

Telephone Number 

Federal Employer ID #- FEIN 

Zip code 

I I 

Page 2 of4 
Section C is to 

be completed by 

New Stage II 

System 

Responsible 

Official(s) only. 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form E 

New Stage II System Owner, Operator, Lessee or 

Controller Notification 

C. Stage II Facility Compliance Certification 

Facility Operation, Maintenance and Record Keeping 

1. Have you obtained and reviewed a copy of your Stage II system's Executive Order and DEP's 

Stage II Facility Training Manual to ensure correct operation and maintenance of your Stage II 

system? 

DYes 0 No (If "No", see Directions For Completing FormE, Section C.) 

Stage II System Responsible Official attesting to compliance status D #1 0 #2 

2. Are the persons conducting required weekly visual inspections of the Stage II System trained to 

operate and maintain the Stage II system in accordance with the system's applicable Executive 

Order? 

DYes D No 

Stage II System Responsible Official attesting to compliance status D#1 0#2 

3. In response to incorrectly installed, non-functioning or broken (broken) Stage II components 

identified as a result of a weekly visual inspection or failed Stage II Compliance Test, are you in 

compliance with the requirements to: 

i. immediately repair the broken Stage II component; or, if the component can not be 

immediately repaired 

ii. immediately stop dispensing gasoline through the broken component, post "Out of 

Service" signs on it, and repaired it within 14 days; or, if the component can not be 

repaired within 14 days 

iii. immediately isolate the broken component from the remainder of the Stage II system so 

that the Stage II system is correctly operating and post "Out of Service" signs on the 

broken component until repaired; 2.[, if the stage II system can not be isolated from the 

broken component so that the Stage II system is correctly operating 

iv. immediately stop all dispensing of gasoline at the facility and post "Out of Service" signs 

on all gasoline dispensers until the component is repaired, applicable tests performed and 

passed, and a fully completed Annual In-Use Compliance Certification submitted to the 

Department as required. 

DYes D No 

Stage II System Responsible Official attesting to compliance status D#1 0#2 

4. Are you in compliance with the requirements to maintain the following records on-site, in a 

centralized location: 

i. All weekly inspection checklists for the prior twelve-month period identifying incorrectly 

installed, non-functioning or broken components, actions taken to repair the Stage II 

system, and the date of repair. 

ii. A copy of Compliance Testing Company test results for all Stage II Compliance 'tests 

performed during the prior twelve-month period. 

iii. A copy of the Stage II system's currently applicable DEP Stage II In-Use Compliance 

Certification. 

iv. Record of all persons trained to perform weekly inspections of the Stage II System. 

DYes D No 

Updated FormE lll.doc · rev. 11/04 Page 3 of 4 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form E 

New Stage II System Owner, Operator, Lessee or 

Controller Notification 

I certify that, where I have indicated that I am the Stage II System Responsible Official, {a) I have personally 

examined the foregoing and am familiar with the information contained in this document and all attachments and that, 

based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the 

information is true, accurate and complete. I am aware that there are significant penalties for submitting false 

information, including possible fines and imprisonment; {b) systems 1 to maintain compliance are in place at the 

facility and will be maintained for the coming year even if the processes or operating procedures are changed over 

the course of the year; and, {c) I am fully authorized to make this attestation on behalf of the facility. 

Printed Name of Stage II System Responsible Official #1 Signature of Stage II System Responsible Official #1 Date 

Printed Name of Stage II System Responsible Official #2 Signature of Stage II System Responsible Official #2 Date 

' For purposes of this statement, "systems to maintain compliance" means procedures that the Stage II facility owner and/ or operator has established 

to ensure that weekly visual inspections and required tests are conducted, that broken or defective components are repaired, replaced or isolated and 

that required records are maintained. 

Updated FormE lll.doc • rev. 11/04 Page 4 of4 
Important: 

When filling out 

forms on the 

computer, use 

only the tab key 

to move your 

cursor- do not 

use the return 

key. 

~ 

~ 

Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention - Stage II Vapor Recovery Program 

Stage II Form F 

Stage II System Closure Notification 

A. Stage II System Documentation 

1. Stage II Facility Name (please print): 

Name of facility where Stage II system installed 

Facility address 

City/town • State 

Department Customer Code # 

Zip code 

2. Stage II System Responsible Official #1 (point of contact for Stage II related correspondence): 

Name of Stage II System Responsible Official #1 (please print) 

Mailing address 

City/town State 

3. Stage II System Responsible Official #2 (fill out only if applicable): 

Name of Stage II System Responsible Official #1 (please print) 

Mailing address 

City/town State 

4. Stage II System Taken Out of Use Status 

i. Is the Stage II system permanently out of service? 

ii. Is the Stage II system temporarily out of service? 

5. Is a fully completed and signed FP-290 Form, issued by the local Fire 

Department, documenting the subject Stage II system is permanently or 

temporarily out of service attached to this Notification? 

Telephone number 

Zip code 

Telephone number 

Zip code 

0 Yes 

0 Yes 

0 Yes 

0 No 

0 No 

0 No 

Please note. For Stage II compliance purposes, the effective date a Stage II system is permanently 

or temporarily taken out of service is the date referenced in the required FP-290 Form. 

Stage II System Responsible Official attesting to Stage II system 

Out of Service status 0 #1 0 #2 

B. Future Property Use 

1. Will the property referenced in this Notification be used for another 

business or commercial operations (for example, auto repair, carwash, 

convenience store, etc.)? 

If yes, please identify: 

0 Yes 0 No 

Updated Form F ll.doc • Summer 2007 Stage II Form F • Page 1 of 2 
Massachusetts Department of Environmental Protection 

Bureau of Waste Prevention- Stage II Vapor Recovery Program 

Stage II Form F 

Stage II System Closure Notification 

2. If you answered Yes to Question B.1 ., has the referenced property been 

sold or leased to a new property owner/operator? 

If Yes, please provide the following new property owner/operator information: 

0 Yes 

Name of New Property Owner/Operator (please print) Telephone number 

Address 

City/town State 

3. What is the effective date the new property owner/operator took control of 

the referenced property? 

C. Compliance Certification 

Zip code 

I 

0 No 

I certify that, where I have indicated that I am the Stage II System Responsible Official, (a) I have 

personally examined the foregoing and am familiar with the information contained in this document and 

all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining 

the information, I believe that the information is true, accurate and complete. I am aware that there are 

significant penalties for submitting false information, including possible fines and imprisonment; and (b) I 

am fully authorized to make this attestation on behalf of the facility. 

Printed name of Stage II System Responsible Official #1 Signature of Stage II System Responsible Official #1 Date 

Printed name of Stage II System Responsible Official #2 Signature of Stage II System Responsible Official #2 Date 

Updated Form F ll.doc • Summer 2007 Stage II Form F • Page 2 of 2 
Executive Order 384 

Small Business Impact Statement 

"· -w}:fJ .. ,. ftc, Overview .. Data ~~ ~ 

,, : ~. 5'~1~-i\:~ 

Agency Department of Environmental Protection 

Secretariat Executive Office of Energy and Environmental Affairs 

CMRNumber 310 CMR 7.24(6) 

Regulation Title Dispensing Motor Vehicle Fuel 

l# .• h _-J:· §niall Business Impact Statem'ent ,/ v' 

Yes No 

Will the requirements of this regulation be readily accessible and useable by small businesses? X 

Does this regulation eliminate any unnecessary or duplicative costs, filing requirements, paperwork X 

burdens, or other administrative requirements that may have a negative impact on small 

businesses? 

Does this regulation provide cross-references to related regulations and other relevant legal X 

requirements? 

Please provide a description of the projected reporting, record keeping and other requirements that 

small businesses will need to comply with as a result of the proposed regulation. 

Businesses that dispense motor vehicle fuel (gasoline) are required to install Stage II vapor 

recovery systems, have them tested annually and certify that their Stage II system is in compliance. 

The business is also required to conduct weekly visual inspections of the vapor recovery system 

and maintain records. 

The proposed changes to the Stage II regulations will clarify applicable compliance testing 

requirements for Stage II system repairs, resulting in elimination of unnecessary compliance testing 

and associated costs when repairs are made to the system. The proposed amendments will also 

eliminate the 120-Day compliance testing and certification requirement lowering facility 

compliance costs. 

Will this regulatory action increase or decrease the costs of small businesses seeking to comply 

with the affected regulatory scheme? If yes, to what extent? 

The proposed amendments will decrease costs to small business where Stage II vapor recovery 

systems are installed in two ways: 

l. New definitions regarding "modifications" to Stage II systems, related requirements for 

testing, record keeping and certification will result in lower compliance cost for all 

facilities. 

2. Elimination of the Vacuum Assist 120-Day in-use compliance testing and certification 

requirement will provide applicable facilities to save $500-$700 in compliance testing and 

certification expenses. 

The proposed amendments will increase compliance cost for certain Balance type Stage II systems 

which will be required to have installed pressure vacuum (PN) caps on all fuel storage tank vent 

lines. The approximate cost of a PN cap is $85. The average cost of compliance testing PN caps is 

$50. 

Are small businesses likely to bear greater costs relative to other businesses in complying with the X 

regulatory action? If yes, to what extent? 

Are there alternative methods for accomplishing the objectives of the regulatory action that might X 

be Jess burdensome to small businesses? If yes, why were such alternatives not_l)__ursued? 

Is it possible to establish less stringent requirements for small businesses, or to exempt small X 

businesses from all or any part of the requirements? 

Is this regulatory action mandated by statute, federal policy or some other authority? If yes, specify X 

which. 

The Stage II Program is required under the Clean Air Act and is included in Massachusetts Ozone 

State Implementation Plan (SIP) for attaining and maintaining compliance with the ozone National 

Ambient Air Quality Standard. 

Does this regulation specify design standards or performance standards? If so, please explain the X 

appropriateness and describe any costs savings associated with using one type of standard instead 

of the other.