### Attachment III Revised Stage II Certification Forms Form A: Installa tion/Substantial Modification Certification (Form B: Not included, eliminated as a result ofproposed amendments) Form C: Annual I n-Use Compliance Certification Form D 1 : Alternative Annual In-Use Compliance Certification (No Testing Required)

Form D2: Alternative Annual In

-Use Compliance Cert ification (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 OnlyImportant: 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 ofWaste 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 offacility 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 fo r 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 Bill i ng 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 4Section B is to be completed by the Compliance Testing Company only
. 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 gasol ine storage tanks are associated with this Stage II System? Done 

## 0 Two or more f. Anticipated amount of gasoline d ispensed 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 Compl iance T esting 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 w ith two or more gasol i ne storage tanks , prior to perform i ng required compliance tests , d id you confirm that the gasoline storage tanks are properly manifolded in accordance w ith 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 Su mmer 2007 Page 2 of 4Secti on C is to be completed by Stage II System Responsible Official(s) on ly . 

### Massach usetts Department of Envi ronmental Protection Bureau ofWaste Prevention - Stage II Vapor Recovery Program 

# Stage II Form A Installation/Substantial Mod ification Certificat ion 

## B . Compliance Testing Company Certification 

## (cont.) 7
. Date each requi red installation compliance test was performed and passed : a. Pressure Decay test b. Vapo r T ie test c. PN Rel ief Vent test d. Dynam ic Back Pressure/Liqu id Blockage test e. Ai r /Liquid Volume Rati o Test f
. Healy Fi llneck Pressure test g . Healy Vapor Return Line test



### , I certify that, (a) 

### I have personally examined the foregoing and am familiar with the information conta ined in Sect ion B. and all attachments that pertain to Section B., and that based on my inquiry of those ind ividuals immed iately respons i ble fo r obtaining the information, 

### I believe that the information is true, accurate and comp lete. 

### I am aware that there are sign ificant penalties for submitting false information, inc lud ing possible fines and i mprisonment; and (b) 

### I am fully authorized to make this attestation on behalf of this Stage 

### II Compliance Testing Company.

Printed name of Compl iance Testing Co. Respons ible Official Signature of Comp li ance 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 T raining Manual to ensure co rrect operation and maintenance of your Stage 

### II system? 

## 0 Yes 

## 0 No (If "No", see D i rections For Completing Form E , Section C.) Stage 

### II System Responsib le 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 ma intain the Stage 

### II system in accordance with the system's applicable Executive Order? DYes 0No Stage II System Responsible Official attesti ng to comp l iance status 

### 0#1 0#2

S2 Form A Summer 2007 Page 3 of4

### Massachusetts Department of Environmental Protection Bureau ofWaste Prevention -Stage II Vapor Recovery Program 

# Stage II Fo rm A Installation/Substa 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. immed iately stop d ispensing gasoline through the broken component, post "Out of Service" signs on it, and repai red it within 14 days; .Q!, if the component can not be repaired within 14 days iii. immediately isolate the broken component from the rema inder of the Stage II system so t hat the Stage II system is correctly operating and post "Out of Service" signs on the broken component until repai red; .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 faci lity 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 twe lve-month period. ii i. 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 Officia l, (a) I have personally examined the foregoing and am fa mi liar with the information contained in this document and all attachments and that, based on my inquiry of those ind ividuals immediately respons ible fo r obtaining the information, I believe that the information is true , accurate and complete. I am aware that there are significant penalties for submitting fa lse 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, t hat broken or defective components are repaired , replaced or isolated and t hat required reco rds are maintained. S2 Form A Summer 2007 Page 4 of4

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 (po int of contact for Stage II correspondence) «RO MaiiCnb> Name of Stage II System Responsible Official 

### «RO MailAddr)) Mailing address 

### «RO _M aiiCity» City /town 

### «RO _MaiiState» 3. Stage II System Responsible Official #2 (fill out only if applicable) «Dsp0fficiai2Cn b> Name of Stage II System Respons ible Official 

### «Dsp0fficiai 2Addr>) Maili ng address 

### «Dsp0fficiai 2City» City/town 

### 4
. Stage II Annual Compliance Fee Billing Address:
Name of pe rson to whom annual compliance fee is billed Name of company Mai l ing add ress 

### «Dsp0fficiai2Sta te» «RO Phn>> Telephone number 

### «RO MaiiZIP» Zip code 

### «Dsp0fficial2Phone))
«Dsp0fficiai2ZIP»

Telephone Number

City/town State Z ip code 

### «CARB_NumCod e», «CARB_SysCiass», 5
. Stage II System Executive Order#: «CARB_SysType» 6. DEP records show your facility to dispense

__________ gallons of gasoline annually. If t his is INCORRECT, please check the box below identifying the correct amount of gasol ine dispensed at your facility (gallons/annually): 

## 0 Less t han 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 t he correct box.

S2FormC Summer 20076/20/07 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 Requ i red to be Performed and Passed. «TestsRequired» 2. Testing and Submittai Dates For th is Form to be subm itted 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 compl iance test in accordance with the applicable test procedure? DYes D No 5. For each requ i red compliance test, provide the :

a. Pressure Decay test b. Vapor T ie test c . PN Rel ief Vent test d. Dynamic Back Pressure/ Liqu id Blockage test e . Ai r /Liqu id Volume Ratio test f. Healy Fill-neck Pressure test g . Hea ly Vapor Return Line test Date Test First Performed Result of Fi rst 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 remai nder of the Stage II system? DYes 

## 0 No If yes, please identify the test and isolated component(s) :

_________________ _ I certify that, (a) I have persona lly examined the foregoing and am familiar with the i nformation contained in Section C
. and all attachments pertaining to Section C ., and that based on my inquiry of those i ndividuals immed iately responsible for obtaining the information, I believe that the information is true , accurate and complete. I am aware that there are sign ificant penalties fo r subm itting false information, including possible fines and imprisonment; and (b) I am fully authorized to make th is attestation on behalf of th is Stage II Compliance Testing Company
.

Printed Name Of Compliance Testi ng Company Responsible Official Signature of Compliance Testing Company Responsib le Official Date Page 2 of56/20/07 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 ma intained 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 Responsib le 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 conduct ing weekly visual inspections tra ined to operate and maintain the Stage II system i n accordance with the system 's appl icable Executive Order? DYes 

## 0 No ( if no, see 0.4 below) Stage II System Responsib le 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-function ing or broken (broken)? DYes DNo IfYES, did you: i. im mediately repair the broken Stage II component; Q!, 

### if the component could not be imm ediately 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 repa ired with in 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 d ispensers until the component is repaired, applicable tests performed and passed, and a fully completed Annual In-Use Compl iance Certification submitted to the Department as required. DYes D No (if no, see 0.4 below) Stage II System Responsible Official attesting to comp liance status D#1 D#2

Page 3 of 56/20/07 

### Massachusetts Department of Environmental Protecti on Customer Code#: 

### Bureau ofWaste 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 I n-Use Compliance test failed on the first try? DYes 

# 0 No If YES, please check the appropriate box below ident ifying your response to the failed test(s), repa i rs made, and date repairs completed in order for the Stage II system to pass failed test(s). Fai led Test Response To Failed Test Repairs And Date Repai rs Completed (pick one, see details below) In Order Fo r 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 ii i. PN Relief Vent test 

# 0 0 0 0 iv
. Dynamic Back Pressure/ 

# 0 0 0 0 Liqu id 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) immed iately 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 repa ired within 14 days (3) immed iately 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 unti l 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 gasol ine dispensers until t he component is repa i red, applicable tests performed and passed , and a f u lly completed Annual In - Use Compl iance Certification submitted to the Department as required. Stage II System Responsible Official attesti ng to compliance status 

### 0#1 0#2 3. Stage II System Record Keeping Are the following records mainta ined on-site, in a centralized location: a . All weekly inspection checklists for the pri or twelve-month period identifying incorrectly installed, nonfunctioning or broken components, actions taken to repai r the Stage I I system, and the date of repai r. · b
. A copy of Compl iance Testing Company test results for all Stage II Compliance tests performed during the prior twelve-month period. c . A copy ofthe 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 56/20/07 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 fo regoing and am fam il iar w i th the information contained in this document and all attachments and that, based on my inq uiry of those indivi duals immed iately responsible for obtain ing the information , I believe that the information is true, accurate and complete. I am aware that there are sign ificant penalties for submitting false information, including possible fines and imprisonment; (b) systems to maintain compliance are in place at the faci lity and will be ma intained fo r the coming year even ifthe processes or operating procedures are changed over the course of the year; and , (c) I am fully authorized to make th is attestation on behalf of the facil ity
. 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 ofWaste 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 offacility 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 MaJ ICntn 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 Respons ibl e Official 

### «Dsp0fficiai2Addr» Maili ng 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 add ress 

### 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 d is pensed 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 ,00 0 ,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 rig ht on the same line or check the correct box.6/20/07 

### Massachusetts Department of Environmental P rotection Customer Code#: 

### Bureau ofWaste Prevention- Stage II Vapor Recovery Program «FacAccounb> 

# Stage II Form 01 Alternative Annual In-Use Compliance Certification (No In-Use Compliance Testin g Requ ired) 

## 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 Ope ration a. Have you operated and ma inta ined t he Stage II system in accordance with t he system's applicable Executive Order? 

## 0 Yes 

## 0 No (if no, see C.4 below) Stage II System Responsible Official attesting to compl iance 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 comp liance 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 comp liance status 

### 0#1 0#2 2. Stage II System Maintenance a . As a result of weekly visual inspect ions, did you fi nd any Stage II system components incorrectly installed , non-functioning or broken (b roken)? DYes 

## 0 No If YES, did you: i. immediately repai r the broken Stage II component; Q!, if t he component could not be immediately repaired ii. immed iately stop dispensing gasoline through t he broken component, post "Out of Service" signs on it, and repaired it within 14 days ; Q!, if the component could not be repaired with in 14 days ii i. 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" s igns on the broken component u nti l 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 of36120107 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 , i n a centra lized location : Customer Code#: 

### «facAccount»

a. All weekly inspection checklists for the prior twelve- month period identifying incorrectly insta lled , nonfunctioning or broken components, actions taken to repa i r 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 ofthe 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 Compl iance 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 add itional 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 i n place at the facility and will be maintained for the coming year even if the processes or operating procedures are changed over the course ofthe 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 Responsibl e 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 Departme nt of Environmenta l Prot ection Bureau ofWaste 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 Docu mentati on 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 Z i p code 2. Stage 

### II System Responsible Officia l #1 (point of contact for Stage II correspondence) «RO M ai i Cnt» Name of Stage II System Responsible Official <<RO MaiiAddr)) Mailing address <<RO MaiiC ity» City/town <<RO_MaiiState)) 

### 3
. Stage II System Responsible Officia l #2 (fill out only if applicable) «Dsp0ffici ai2Cnb> Name of Stage II System Respons ible Official <<Dsp0ffic i ai2Addr)) Mailing address «Dsp0ffi c i ai2C ity>> City/town 4. Stage II Annual Compliance Fee Bill ing Address: Name of person to whom annual complia nce fee is b i lled Name of company Mailing address <<Dsp0fficiai2Sta te)) «RO Phn» Telephone number <<RO MaiiZIP)) Zip code «Dsp0fficiai 2Phone))
<<Dsp0ffi ciai 2ZI P))

Telephone Number

City/town State Z i p code 5
. Stage 

### II System Executive Order#: <<CARCBA_RNBumSCodTe», <<CARB

_SysC i ass)) , << _ ys ype» 6. DEP records show your facility to dispense - -- ------ - gallons of gasoline annually. Ifthis is I NCORRECT, p lease check the box be low identify ing the correct amount of gasoline dispensed at your faci lity (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 a re associated with 

### this Stage II system? · 8. Is the pre-completed Stage II system documentation conta ined 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 co rr ect box.6120107 

### Massachusetts Department of Environmental Protection Bureau ofWaste Prevention- Stage II Vapor Recovery Program 

# Stage II Form 02 Annual In-Use Compl iance Ce rtification 

### (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 Rel i efVent test d. Dynamic Back Pressure/ Liquid B lockage test e. Air/Liquid Vo lume 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 ofthe 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 fami liar w ith 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 Responsibl e Offici al Signature of Compliance Testing Company Responsible Official Date

Page 2 of 56/20/07 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 I I 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 N o (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 repa ir the broken Stage II component; .Q!, 

### if the component could not be immediately repa ired 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 i s correctly operating and post "Out of Servicen signs on the broken component until repa ired ; .Q!, 

### ifthe stage 

### II system could not be isolated from the broken component so that the Stage 

### II system is correctly operati ng 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 56/20/07 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 I I 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!, ifthe component co uld 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 fro m 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 fu lly 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 ofWaste Prevention - Stage II Vapor Recovery Program 

# Stage II Form E New Stage II System Owner, Ope rator, 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 policyTreasu rer 

## 0 0 making or decision -making function of the Corporation If a Partnersh ip, a general partner If a Sole Proprietorship , the proprietor If a municipality/public agency, a principa l 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 p rovide 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 Ifyes , 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 of4Section C is to be completed by New Stage II System Responsible Official(s) only
. 

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 ma intenance of your Stage II system? DYes 0 No (If "No", see Directions For Completing FormE , Section C
.) Stage II System Responsible Official attesting to comp liance status D #1 0 #2 2. Are the persons conducting requ ired weekly visual inspections of the Stage II System trained to operate and ma inta in the Stage II system in accordance with the system's applicable Executive Order? DYes D No Stage II System Responsible Official attesting to comp liance 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 v isual inspection or fai led Stage II Compliance Test, are you in compliance with the requirements to: i. immediately repa ir the broken Stage II component; or, if the component can not be immediately repaired i i. i mmediately stop dispensing gasol ine th rough the broken component, post "Out of Service" signs on it, and repaired it withi n 14 days; or, if the component can not be repai red within 14 days i ii
. immed iately isolate the broken component from t he 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 unti l repaired ; 2.[, 

### if the stage II system can not be isolated from t he broken component so t hat the Stage II system is correctly operating iv . immediately stop 

### all dispensing of gasoline at the facil ity 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 subm itted to the Department as requi red. DYes D No Stage II System Respons ible Official attesting to compliance status D#1 0#2 4
. Are you in comp liance with the requirements to maintain the following records on-site , in a centra lized location: i. All weekly inspection checkl ists for the prior twelve-month period identifying i ncorrectly i nstalled, non-function ing or broken components, actions taken to repair the Stage II system, and the date of repa ir. ii. A copy of Compl iance Testing Company test res ults fo r all Stage II Compl iance'tests performed during the prior twelve-month pe ri od
. i i i. A copy of the Stage II system 's currently applicable DEP Stage II I n-Use Compliance Certification
. iv. Record of all persons trained to perform weekly inspections of the Stage II System. DYes D No
Updated FormE ll l.doc · rev. 11/04 Page 3 of 4

### Massachusetts Department of Environmental Protection Bureau ofWaste 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 inq uiry of those individuals immediately responsible fo r obtaining the information, I believe that the i nformation is true, accurate and complete. I am aware that there are significant penalties for submitting false i nformation, includi ng possible fines and imprisonment; {b) systems1 to maintain compliance are in place at the facility and will be mainta ined 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 behal f 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 repa ir ed, replaced or isolated and that required records are maintained
.

Updated FormE lll.doc • rev. 11/04 Page 4 of4Important: 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 ofWaste Prevention - Stage II Vapor Recovery Program 

# Stage II Form F Stage II System Closure Notification 

## A. Stage II System Documentation 1. Stage 

### II Facil ity Name (please print):
Name offacility 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 appl icab le):
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? i i. 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
P lease 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 fo r 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 ofWaste 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 Respons ible 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 immediate ly responsible for obtaining the info rmation , I believe that the informat ion is true , accurate and complete. I am aware that there are sign ificant 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 Responsi b le Official #2 Si gnature of Stage II System Respons i ble Official #2 Date

Updated Form F ll
.doc • S ummer 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 ofEnvironmental Protection Secretariat Executive Office of Energy and Environmental Affairs CMRNumber 310 CMR 7.24(6) Regulation Title Dispensing Motor Vehicle Fuel l#
.

• h



# _ -J:·**§nial l**  Business Impact Statem 'ent ,/ 

### v' Yes 

### No Will the requirements ofthis regulation be readily accessible and useable by small businesses? 

### X Does this regulation elimina te 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 ofthe 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 ofthe 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 faci lity compliance costs. Will this regulatory action increase or decrease the costs ofsmall businesses seeki ng t o comply with the affected regulatory scheme? Ifyes, 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 ofthe 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 ofa 

### PN cap is $85. The average cost ofcompliance 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 ofthe regulatory action that might 

### X be Jess burdensome to small businesses? Ifyes, 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 ofthe 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 regula tion specify design standards or performance standards? Ifso, please explain the 

### X appropriateness and describe any costs savings associated with using one type ofstandard instead ofthe other.