Form Il 532-2648 - Registration Form - Stage Ii Vapor Recovery System - State Of Illinois

ADVERTISEMENT

STATE OF ILLINOIS
For Administrative
Use Leave Blank
REGISTRATION
STAGE II VAPOR RECOVERY SYSTEM
NOTE: Any new station in Cook, DuPage, Kane, Lake, McHenry and Will Counties, Oswego Township in Kendall
County and Goose Lake and Aux Sable Townships in Grundy County with projected average sales of 10,000 gallons
of gasoline per month or an existing station that exceeds 10,000 gallons of gasoline average per month must install and
operate a State II System. Complete and retain a copy of this form for your records. A copy of all forms and
d
ocuments must be kept at each station.
1.
LOCAL STATION REGISTRATION:
Station Name____________________________________________Phone (
)
Fuel Brand Name Sold ____________________________________________________________
Street Address___________________________________________________________________
City, State ________________________________________________ Zip
On-site Station Manager __________________________________________________________
Email _________________________________________________________________________
2.
REGIONAL CORPORATE/INDEPENDENT OWNER INFORMATION:
Corporate/Owner Name______________________________Phone (
)
Corporate Contact Name _____________________________Phone (
)
Street Address___________________________________________________________________
City, State _______________________________________________ Zip
Email _________________________________________________________________________
3.
TYPE OF REGISTRATION:
New Station
Stage II Equipment Changes
Owner/Contact/Address Change
Stage II Certificate Replacement
4.
VAPOR RECOVERY SYSTEM:
Manufacturer’s Name and Model Number
Date Stage II System became operational*
*For new gas stations or for newly installed Stage II Systems the month/year the system became operational.
NOZZLES (excluding diesel fuel and kerosene):
Manufacturer’s Name
Model #
The Number of This Type of
Nozzle
5.
VOLUME OF GASOLINE DISPENSED:
For Existing Stations, Current Average Monthly Volume _______________________________
For New Stations, Projected Average Monthly Volume _________________________________
6.
Signature of Individual Completing This Form ______________________________________
Print Name__________________________________________________Date_______________
Mail the original copy to:
Illinois Environmental Protection Agency
Stage II Vapor Recovery Program, MC #6
P.O. Box 19276
Springfield, IL 62794-9276
Questions? Call (217) 557-1441.
The Illinois EPA is authorized to require, and you must disclose, the information on this required form pursuant to the Illinois Pollution Control Board Rules and
Regulations, 35 Ill. Adm. Code 218.586. Failure to disclose the information may result in penalties as provided for in the Act, 415 ILCS 5/42-45. This form has
been approved by the Forms Management Center.
IL 532-2648
APC 590 Rev. 08/2007

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2