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Form 1a - The Commonwealth Of Massachusetts Department Of Fire Services - Certificate Of Compliance (Form Fp-056a)

The Commonwealth of Massachusetts

Department of Fire Services

527 CMR 1.00

FP-056A

Section 11.5.1.10.10.1

(Rev. 1.26.2015)

Form 1A

Certificate of Compliance

M.G.L. Chapter 148, Section 38J

City or Town: _____________________________________________________________________________

Street Name & Number: ____________________________________________________________________

Name of Property Owner: ___________________________________________________________________

This certifies that a visual inspection of the fuel supply line(s) for the aboveground heating oil storage

tank was completed in accordance with M.G.L. Chapter 148, Section 38J (d) for the residential property

identified above, and the following equipment was observed:

 Each fuel supply/return line is enclosed with a continuous non-metallic sleeve

 Each fuel supply/return line is equipped with an oil safety valve

 Each fuel supply/return line is not in direct contact with concrete, earth or any floor surface. No oil

safety valve or continuous non-metallic sleeve is required.

 Burner is located above the fuel storage tank and the entire fuel line is connected to, and above

the top of the tank. No oil safety valve or continuous non-metallic sleeve is required.

This visual inspection and certification of compliance was completed on:

Date: ___________________________________________________________________________________

By: (Signature of Oil Burner Technician) _______________________________________________________

(Print Name of Oil Burner Technician) _________________________________________________________

Certificate of Competency #: ________________________________________________________________

Upon completion of Form 1A, the property owner shall receive a copy of the form and

a copy shall also be submitted to the head of the local fire department or a designee.

This form can be photocopied or reproduced in triplicate.

Form 1a - The Commonwealth Of Massachusetts Department Of Fire Services - Certificate Of Compliance (Form Fp-056a)