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Appendix 1

Application for Certificate of Compliance for Dispensing Facilities

THE COMMONWEALTH OF MASSACHUSETTS

Department of Revenue

Underground Storage Tank Board

100 Cambridge Street, 7

Floor – P.O. Box 9563

Boston, Massachusetts 02114

CERTIFICATE OF COMPLIANCE APPLICATION WITH BOARD ACCEPTABLE SITE ASSESSMENT

I. INSTRUCTIONS

Please type or print in ink and sign the owner/operator certification on the reverse side. A Board Acceptable Site Assessment (BASA)

and a copy of the current Facility Detail Report from MassDEP’s online UST Data Management System (DMS) must accompany

this application. Please note that the facility owner identified in Section II below must match the information in the MassDEP UST

DMS. Also enclose a copy of:

(1) If a Marina, a Marine Fueling Permit (FP-294)

(2) Applicable current testing reports (cathodic protection, product line, line leak detector, etc.)

Note: The UST Program encourages you to use our internet-based “eUST” application to submit and manage your Certificate of

Compliance (COC) Application in lieu of this paper form. Please visit our website for more information:

II. OWNERSHIP OF TANK(S)

III. LOCATION OF TANK(S)

_______________________________________________________

______________________________________________________________

Owner Name (Corporation, Individual, or Other Entity)

Facility Name (Corporation, Individual, or Other Entity)

________________________________________________________

_____________________________________________________________

Street Address

Street Address (P.O. Box not acceptable)

_____________________________________________________________

_________________________________________________________________________________

City

State

Zip

City

State

Zip

___________________________________________________________ _

_________________________________________

_________________________

County

Mail Address if Different from Street Address

_____________________________________________________________

_________________________________________ _______________________________________

Phone Number (Include Area Code)

Phone Number (include Area Code)

– UST Facility Identification Number: _____________

IV. GENERAL

attached?

Attached

Facility Detail Report

BASA attached or previously submitted?

Attached

Previously submitted

UST COMPLIANCE TESTING

Cathodic Protection System Testing: Check applicable box

Not Applicable - UST system is Fiberglass, Composite, etc.

Sacrificial Anode System

Annual test (- 0.85 V to - 0.90 V) or

3-yr test ( > - 0.90 V) - Attach report.

Impressed Current System - Attach annual test survey report

Product Piping Test Report: Check applicable box

Pressurized - Attach annual line and line leak detector test report.

Pressurized equipped with interstitial monitoring - Attach product line leak detector test report.

Suction, check valve at tank - Attach 3-year test report (No test required if equipped with interstitial monitor)

Suction, check valve at dispenser only, none at tank– No test required.

Note: Failure to provide applicable test reports may result in the disapproval of the COC application.

Continued on Reverse Side

Form 21J- Appendix 1 (Rev. 9/10/15) Page 1 of 2.

Form 21j - Appendix 1 - Application For Certificate Of Compliance For Dispensing Facilities

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